Fitness Section Application Form
Welcome to the Fitness Section. This form is to be completed by the applicant. This form is confidential and is retained in your personal fitness file.
Full Name
First Name
Last Name
Member Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal Code
Phone Number
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Area Code
Phone Number
Date of Birth
Emergency Contact
First Name
Last Name
Emergency Phone
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Area Code
Phone Number
Doctor Name
First Name
Last Name
Doctor Phone
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Area Code
Phone Number
Physical Activity Readiness Questionnaire
If you are 69 years of age or over, you must obtain medical clearance from your doctor. A written and signed consent form must be presented to the section by your doctor, giving you clearance to participate in a prescribed exercise program. Please answer the questions below:
1. Has your Doctor ever said that you have a heart condition and as a result should only participate in a medically recommended physical activity?
Yes
No
2. Do you feel pain in your chest when you are involved in physical activity?
Yes
No
3. In the past month, have you had chest pain when you were not engaging in physical activity?
Yes
No
4. Do you lose balance because of dizziness or have you ever lost consciousness?
Yes
No
5. Do you have a bone or joint problem that could be aggravated by a change in your physical activity?
Yes
No
6. Is your Doctor Currently prescribing drugs for your blood pressure or heart condition?
Yes
No
7. Do you know of any other reason why you should not engage in physical activity?
Yes
No
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