Registration & Consent Form & Health Questionnaire

Youth Athletic Performance Program 2009

Personal Info

Name: E-mail

Day Phone (xxx-xxx-xxxx): Eve Phone: Other Phone:

Street Address:

City: State: CT NJ NY PA ZIP Date of Birth (MM/DD/YY):

Parent(s) name(s):

Program Guidelines

Session Choice

Mon. 6pm only

Tue. noon only

Wed. 6pm only

Thu. noon only

Mon/Wed 6pm

Tue/Thu noon

 

I agree that I will be participating in a group training program that will meet 2x per week either Monday/Wednesday at 6pm or Tuesday/Thursday at noon. I have indicated my choice of one or two weekly sessions, and sessions will be 60 minutes in length. The monthly program fee of $200 (two sessions weekly) or $120 (one session weekly) will be paid by check payable to “ONE Human Performance” prior to the commencement of the first training session or using the OHP Online Store. I understand that program fees are non-refundable and credit will not be given for missed sessions.

1.	Has a doctor ever said you have a heart condition and recommended only supervised physical activity?	Yes No
2.	Do you have chest pain brought on by physical activity?	Yes No
3.	Do you tend to lose consciousness or fall over as a result of dizziness?	Yes No
4.	Has a doctor ever recommended medication for your blood pressure or a heart condition?	Yes No
5.	Do you have a bone or joint problem that could be aggravated by the proposed physical activity?	Yes No
6.	Are you aware, through your own experiences or a doctor’s advice, of any physical reason against your exercising without medical supervision?	Yes No
7.	Are you over the age of 65 and not accustomed to rigorous exercise?	Yes No
8.	Are you currently or have you been pregnant within the last six months?	Yes No

If you answered YES to one or more of the questions above, please answer the following questions:

9	Have you consulted your physician regarding increasing your physical activity and/or performing a fitness assessment?	Yes No
10.	If you answered "yes" to question 8, will you consult your physician prior to increasing your physical activity and/or performing a fitness assessment?	Yes No

Do you now have, have you recently experienced, or have you ever had:
(Check all those that apply, leave others blank)

	Heart attack, coronary bypass, or stroke		High/Low Blood Cholesterol
	Extra, skipped or rapid heart beats/palpitations		High/Low Blood Pressure
	Asthma, respiratory problems, pulmonary disease		Diabetes
	Thyroid Condition		HIV or AIDS virus
	Arthritis, orthopedic problems		Cancer
	Bone or joint disorders, or injuries		Kidney disease
	Ulcer		Neuromuscular disease
	Arteriosclerosis		Bulimia or Anorexia
	Increased anxiety or depression		Emotional disorders
	Fatigue, lack of energy		Trouble sleeping

By submitting this form, I understand the risks inherent with this event and agree to all program parameters. I do not hold liable One Human Performance Center or any of its representatives or employees. I will notify the proper individuals as to any risk factors and/or medical concerns that may affect my participation.

 

Thank you!