Online Registration Form Prefer a hard copy? Click here REGISTRATION/MEDICAL HISTORY/WAIVER FORM Before beginning any exercise program, consult with your physician. "*" indicates required fields This field is hidden when viewing the formBefore beginning any exercise program, consult with your physician.Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Phone*Birthday* MM slash DD slash YYYY Do you consent to receiving texts/emails?* Texts Emails Medical History Have you now or have you had in the past:History of heart problems, chest pain or stroke?* Yes No Please ExplainIncreased blood pressure or blood cholesterol?* Yes No Please ExplainAny chronic illness or condition?* Yes No Please ExplainDifficulty with physical exercise?* Yes No Please ExplainAdvice from physician not to exercise?* Yes No Please ExplainRecent surgery (last 12 months)?* Yes No Please ExplainPregnancy (now or within the last 3 months)?* Yes No Please ExplainHistory of breathing or lung problems?* Yes No Please ExplainMuscle, joint or back disorder, or any previous injury still affecting you?* Yes No Please ExplainDiabetes or thyroid condition?* Yes No Please ExplainCigarette smoking habit?* Yes No Please ExplainMore than 20% over ideal body weight?* Yes No Please ExplainIncreased blood cholesterol?* Yes No Please ExplainHistory of heart problems in the immediate family?* Yes No Please ExplainHernia or any condition that may be aggravated by lifting weights?* Yes No Please ExplainAre you currently on any medications?* Yes No Please list all medications/supplements and their dosagesWaiver*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 dba Health Is Not A Club, or its instructors, coaches or trainers liable in the event of personal injury. ACCEPTEmergency Contact* Name Phone number Relationship Physician* Name/Phone number CommentsThis field is for validation purposes and should be left unchanged.