Registering For:
Personal Information; All
information provided is confidential.
Last Name First
Name MI Birth Date MM/DD/YYYY; AGE;
Gender M/F
Address City State Zip
Home Phone Work/Cell
Phone Email
Emergency Contact Person Emergency
Contact Phone
Physician Physician
Phone
Smoking Quit; When Packs/Day
Other
Tobacco Products, List
Are you pregnant, nursing, or less than six weeks postpartum
Have you ever had a heart attack or has your doctor said that you have cardiovascular disease
Do
you have frequent chest pains
Do
you have frequent Shortness of Breath
Do you have high blood pressure
Do you often feel faint or dizziness
Do
you have high cholesterol
Do you have diabetes Insulin Dependent; how long
Do you have bone or joint problems; such as arthritis that is aggravated by exercise
Are you accustomed to moderate activity or exercise
Is there a good physical reason why you should not follow an activity program
Other medical history concerns or operations:
List current medications:
List allergies:
What are your Goals:
Payment Information:
8 week Yoga Class $40 8
week Kid’s Yoga Class $30
8 week Low Impact Aerobics $20
Submit forms and
make checks to Hickory Gove UMC Recreation,
Hickory
Grove United Methodist Church Recreation Ministry