THE GALLERY AT SOUTH DEKALB

FITNESS CLASS REGISTRATION

** Participant Information:

Name (Last, First):______________________________________________________________________

Address:______________________________________________________________________________

Phone:_______________ Age: _____  Gender: _____  Race: _____ Do you live in Dekalb County: _____

Email:________________________________________________________________________________

  ___Please add me to your email list!

Business/Organization:___________________________________________________________________

**Medical Clearance & Participation Waiver:

I have agreed to participate in a program of physical activity including, but not limited to aerobic conditioning. I do hereby affirm and declare myself physically sound and I do not suffer from any condition, disease, disability, or other illness or impairment which would prevent or limit my participation in the community aerobics classes being offered at The Gallery at South DeKalb.   In consideration of my participation in the program and the activities offered by JoANNAWard Fitness, Hallelujah Productions, LLC, Thor Gallery at South Dekalb, LLC, The Gallery at South Dekalb Merchants Association and Thor Equities, LLC., I for myself, my heirs and assigns, do hereby waive, release, and forever discharge JoANNA Ward Fitness, Hallelujah Productions, LLC, Thor Gallery at South DeKalb, LLC, The Gallery at South Dekalb Merchants Association and Thor Equities, LLC, owners, representatives, and all others from any and all responsibility, and causes of action arising from my participation in the aerobic classes. I fully understand the risk of injury that could result from my voluntary participation in the aerobic activities while at The Gallery at South DeKalb and I hereby release JoANNA Ward Fitness, Hallelujah Productions, LLC, Thor Gallery at South DeKalb, LLC, The Gallery at South DeKalb Merchants Association and Thor Equities, LLC, and all others, paid and volunteer, from any liability or responsibility now or in the future including, but not limited to heart attacks, muscle strains and sprains, pulls or tears, broken bones, shin splints, heat prostration, foot, back, knee injuries, and any other soreness, illness or other injury however caused, occurring during or after my participation in any fitness programs offered by JoANNA Ward Fitness, Hallelujah Productions, LLC, Thor Gallery at South DeKalb, LLC, The Gallery at South DeKalb Merchants Association and Thor Equities, LLC.

I further acknowledge that I am aware of the terms and conditions of participation in the aforementioned programs and have received a completed copy of such agreement on this ________day of____________2006.

Signature:___________________________________________________  Date:____________________

Survey:

How many times per week do you exercise? Never_____  2-3 _____  3+______

What is your fitness awareness level? Advanced_______ Amateur_____ I don’t know______

Is this your first time ever participating in a fitness class? Yes____ No_____

Do you like the idea of exercising at The Gallery at South DeKalb? Yes____ No____ I don’t know yet____

Are you looking for a personal trainer? Yes____ No____  Should one contact you? Yes___ No___

Are you interested in other health related programs offered by The Gallery at South Dekalb?

Yes___ No___

Which best describes your mood about participation? Nervous____ Afraid____ Excited ____ Anxious____

Would you be willing to participate in a televised fitness show? Yes___ No ____

***Health History/ Physical Activity Questionnaire:(All information provided will be kept confidential)

1. List medical complaints:  ______________________________________________________________________________________________________________________________________________________________
2. Have you ever been hospitalized, treated for serious illness or surgery?_______________________________________________________________________________________________________________________________________________________
3. Explain any surgery or injury that would hinder or prohibit your participation in an exercise program._____________________________________________________________________________________________________________________________________________________
4. Are you currently under a physician’s care for any physical health problem? Yes ____ No ____

If yes, for what reason?____________________________________________________________

5. Are you aware of any problems that would keep you from participating in regular, vigorous, physical activity? Yes ____ No ____

If yes, explain___________________________________________________________________

6. Are you currently taking any medication (prescription and non-prescription)? Yes ____ No ____

If yes, fill in below:

Medication___________________Dose____________Reason______________How long?_____

       Check all that have ever applied to you:

       ___rheumatic fever   ___high cholesterol    ___high blood pressure  ___infections  ___aneurysm 

       ___asthma  ___embolism  ___stroke  ___diabetes  ___edema/swelling  ___pneumonia  

       ___heart murmur  ___arthritis  ___neck problems  ___back problems  ___foot problems 

       Are you on a diet? _________ Do you consider yourself to be overweight?__________

       Do you eat breakfast? ______________ How many meals per day do you eat?_________