* - Required Field
First Name: *
Last Name: *
Student ID Number that begins with 000- or 88-: *
Which class are you enrolled: * TTh 8:05 am to 9:30 am TTh 9:40 am to 11:05 am TTh 11:15 am to 12:40 pm Sat 10:00 am to 12:00 pm Thurs 7:35 pm to 9:30 pm MW 8:05 am to 9:30 am MW 9:40 am to 11:05 am MTWTh 8:00 AM to 10:25 AM MTWTh 6:00 PM to 8:10 PM
Address: *
City: *
State:*
Zip:*
E-mail Address: *
Contact Phone Number (including the area code):* Only use numbers. No spaces, hyphens or parenthesis.
You should use your cell phone.
What is your heart rate?:* Take your heart rate for one full minute.
How much do you weigh?:*
Date of Birth:*
Age:*
Gender* Male Female
Have you taken this course?:* No Yes
Do you take any medications?:* No Yes
Explain:*
Do you have any allergies?:* No Yes
Do you have any medical problems?:* No Yes
In case of an emergency, who should we contact (preferably a parent)?
Name:*
Contact phone (please include the area code):* Only use numbers. No spaces, hyphens or parenthesis.
Relationship?:* Parent Sibling Grandparent Friend Spouse
1. Has your doctor ever said you had a heart condition and that you should only do physical activity recommended by a doctor? (If you answer yes to this question, you must get a doctor's note stating you can take this class):*
No Yes
2. Do you feel pain in your chest when you do physical activity? (If you answer yes to this question, you must get a doctor's note stating you can take this class):
3. In the past 30 days, have you had chest pain when you were not doing physical activity? (If you answer yes to this question, you must get a doctor's note stating you can take this class):
4. Do you lose your balance because of dizziness or do you ever lose consciousness? Please do not answer yes if you get dizzy because you have not eaten. (If you answer yes to this question, you must get a doctor's note stating you can take this class):
5. Do you have bone or joint problems that could be made worse by a changing your physical activity? (If you answer yes to this question, you must get a doctor's note stating you can take this class):
6. Is your doctor currently prescribing medication for your blood pressure or heart condition? (If you answer yes to this question, you must get a doctor's note stating you can take this class):
7. Do you have diabetes?
8. Do you have asthma? If yes, you must carry your inhaler with you at all times, NO EXCEPTIONS!
9. Are you pregnant or do you think you might be pregnant? (If you answer yes to this question, you must get a doctor's note stating you can take this class):
10. Do you have problems with seizures? (If you answer yes to this question, you must get a doctor's note stating you can take this class):
11. Do you smoke cigarettes? If yes, how many per day?
12. Do you, or any member of your family, have a history of heart disease?
13. Do you know of any other reason why you should not do physical activity?
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