I would like to participate in Kickboxing Fitness Classes.
I would like to register for the Kickboxing WLT.
I would like to engage a Personal Trainer.
If you have serious medical conditions, please seek your Doctor's approval.
3-minute Par-Q (Physical Activity Readiness Questionnaire)
1. Do you feel any discomfort in your chest when you do physical activity?
YES
NO
If YES, please give details.
2. Do you experience dizziness engaging in strenuous activities?
YES
NO
If YES, please give details.
3. Do you have a bone or joint problem that could be aggravated by a change in your physical activity?
YES
NO
If YES, please give details.
4. Are you currently participating in any regular activity program designed to improve or maintain your physical fitness?
YES
NO
If YES, what activity program do you participate in?
If NO, do you know of any other reason why you should not do physical activity?
MEDICAL HISTORY
1. Cardiovascular Disease Risk Factor
Has a doctor or health professional ever told you that you have any of the following conditions?
Heart Disease
Family history of heart disease
High Blood Pressure
High Cholesterol
Obesity
Lack of physical activity
Diabetes
None of the above
2. Medication Use
Are you currently taking any of the following medication:
Not Taking Any Medication
Blood Pressure Medication
Cholesterol Medication
Blood Sugar Medication
Heart Medication
Other Medication
If YES, please list:
3. Do you have any of the following?
Back Pain
Joint, tendon or muscular pain
Lung disease (asthma, emphysema, etc)
None of the above
4. Which best describes your current smoking status?
I have NEVER smoked.
I currently SMOKE.
I quit within the last 6 months.
I quit more than 6 months ago.
If YES, please list:
5. How would you rate your overall state of health?
Poor
Fair
Good
Excellent
I, hereby request the opportunity to participate in BX Fitness Programs consisting of physical exercise designed to improve cardiovascular efficiency, improve flexibility and develop muscular strength and endurance. I hereby acknowledge that my participation in such program is entirely voluntary on my part. My participation does not arise out or in the course of employment with Beyond Xtreme and is not a requirement of any such employment. Such participation is solely for my own pleasure and benefit.
I will be taught how to properly operate all equipment necessary for my participation. I realize that the physical fitness equipment provided can be potentially dangerous and that if I am unsure of the proper operation of any equipment, I should ask for assistance from the fitness staff. In addition, I understand that I should immediately cease using any malfunctioning equipment and report to the fitness staff equipment in need of repair.
I recognize that exercise carries some risk to the musculoskeletal system (sprains, strains) and the cardiorespiratory system (dizziness, discomfort in breathing, heart attack). It is possible that certain unhealthy changes may occur during exercise (e.g., dizziness/fainting, abnormal heart rhythms, and in rare instances, heart attacks, and death). I hereby accept all risks of such changes. The information which is obtained through this program will be confidential and become a part of my Beyond Xtreme medical records. The data obtained, however, may be used for statistical purposes.
In consideration of acceptance of my participation in such program and understanding that I am personally responsible for my actions during my sessions with Beyond Xtreme, I hereby release Beyond Xtreme and all officers, directors, employees and agents (as a group and as individuals) of any of the foregoing for liability if I should incur any illness, injury or even death while participating in such a program as a result of my negligence.
I have understood the terms and conditions to register myself for classes with
Beyond Xtreme.
