Name*
Date of Birth (mm/dd/yy)*
Phone # (H): *
Address*
Phone # (W):
Email Address*
Physician's Name:
Emergency Contact:
Emergency Contact Phone #:
How did you hear of 1st Page Fitness?*
Oxford JournalFriendWebsiteOxford Community Events PaperAmherst Daily NewsSobeys BulletinOther
Existing Medical Conditions - Please check all that appl
diabetes asthma heart condition pregnancy arthritis obesity high cholesterol anaemia thyroid problems high blood pressure hearing loss epilepsy eye problems
Do you have pain or have you injured any of the following areas:
neck upper back lower back shoulder elbow wrist hip knee ankle
Do you smoke?
Yes No
Which location are you registering for?
Oxford Pugwash
Which class are you registering for?*
Boot CampStability BalBoth
