Online Registration Form

Before beginning any exercise program, consult with your physician.

Name*

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Phone

Birthday*

Do you consent to receiving texts/emails?*

Texts
Emails

Medical History*

Have you now or have you had in the past:

Waiver*

Due to the physical demands of aerobic, strength, balance and flexibility training, I understand that there is an inherent risk of personal injury by participating, and I accept complete responsibility for my health and well-being in this program. I will not hold State of the Heart Fitness LLC or its instructors, coaches or trainers liable in the event of personal injury.

ACCEPT

Emergency Contact

Name Phone number Relationship

Physician

Name/Phone number

Registration/Medical History/Waiver Form

Before beginning any exercise program, consult with your physician.

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