Name *

First Name

Last Name

Phone

(###)

###

####

Have you been medically cleared to participate in fitness activities? *

Yes

No

I'm not sure

Are you currently undergoing any physical therapy? *

Yes

No

Is this your first experience with a fitness program? *

Yes

No

Do you have reliable transportation? *

Yes

No

How would you assess your current level of commitment and dedication? *

None

Low

Average

High

Exceptional