Ultimate Rockstar

Jonathan11 May 2020

Terms:

£25 / Month

First Name:* First Name Required

Last Name:* Last Name Required

Address Line 1:* Address Line 1 is Required

Address Line 2: Address Line 2 is not valid

City:* City is Required

Country:* Country is Required

State/Province:* State/Province is Required

Zip/Postal Code:* Zip/Postal Code is Required

D.O.B:* D.O.B is Required

Telephone:* Telephone is Required

Emergency Contact

Name:*

Emergency Contact

Name is Required

Relationship to you:* Relationship to you is Required

Emergency Telephone:* Emergency Telephone is Required

Activity Questionaire

Have you ever had a heart condition? :*

Activity Questionaire

Have you ever had a heart condition? is Required

Yes No

(If yes please specify what condition): (If yes please specify what condition) is not valid

Do you have any bone or joint problems?:* Do you have any bone or joint problems? is Required

Yes No

(If yes which joints are effected?): (If yes which joints are effected?) is not valid

Are you currently taking any prescribed medication?:* Are you currently taking any prescribed medication? is Required

Yes No

(If yes, what medication?): (If yes, what medication?) is not valid

Have you had any surgery in the past year?:* Have you had any surgery in the past year? is Required

Yes No

(If yes, when and what was it for?): (If yes, when and what was it for?) is not valid

Do you ever experience chest pain?:* Do you ever experience chest pain? is Required

Yes No

Are you prone to fainting?:* Are you prone to fainting? is Required

Yes No

Do you have diabetes?:* Do you have diabetes? is Required

Yes No

Do you have high blood pressure?:* Do you have high blood pressure? is Required

Yes No

Are you pregnant?:* Are you pregnant? is Required

Yes No

(If so, how far along are you?): (If so, how far along are you?) is not valid

Do you know of any other health issue or any other reason why you should not take part in physical activity?:* Do you know of any other health issue or any other reason why you should not take part in physical activity? is Required

Yes No

Details: Details is not valid

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Password Confirmation:* Password Confirmation Doesn't Match

Password Strength Password must be "Medium" or stronger

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Terms: £25 / Month

Description	Amount
Ultimate Rockstar – Initial Payment	£25.00
Total	£25.00

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I confirm that I have read, understood and completed the RockFit activity questionnaire. I confirm my answers are true and accurate to the best of my knowledge. It is my responsibility to notify my instructor immediately of any changes to the answers I have given or if I have any concerns.

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