Sportsmetrics Registration Form
Baylor All Saints Medical Center
CarterRehabilitation & FitnessCenter
Sportsmetrics Registration
1400 Eighth Ave.Ft. Worth, TX76104
817-922-1217 Aaron Saldivar or 817-922-2194 Jake Schwarz 817-922-2535 fax
Sportsmetrics will be offered: Session 1 - May 5 – June 13; and againSession 2 - June 30 – August 8. Classes will be held from 5:30-6:30p.m. on Mondays, Wednesdays, and Fridays of each week. A pre test will need to be completed on or before the first day of the program. The pre test will include: vertical jump testing; hamstring flexibility; knee assessment; general posture and alignment assessment; jumping/landing digital videocomputer analysis. You will be contacted upon receipt of your application to schedule a time for the pre-test.
Cost: $275 Make checks payable to Carter Rehab & Fitness Center (CRFC). Credit card payment can be made in person at the front desk of the CRFC. All payments and registration forms must be turned in by the registration deadline. Please use the complete address above if you are mailing in your registration.
Registration Deadline: May 2 (for session 1) and June 27 (for session 2). Class capacity is 12 participants per session. Classes will be filledon a first come first serve basis in the order in which registration forms are received.
Participant Information
Name: lastfirst / date of birth Age genderM / F
street Address / citystatezip
Contact number / Which Session Will you Be Attending?
Session 1 (May 5-June 13) ____
Session 2 (June 30-August 8) ____
E-Mail Address (optional) / primary care physicianphone
Emergency Contact: namedaytime phone /
evening phonerelationship
sports played: / will you be partipating in a sports season during the Program?Health Appraisal: Medical History
It is our purpose to provide a safe and effective training program for you. It is of significant help to us for you to fill this section out as completely and accurately as possible.
Risk FactorDo you have this or are being treated for it?Please explain (attach records or pages if needed)Surgery / Hospitalization yes/no
Knee injury within the last year yes/no
Knee pain yes/no
Heart murmur yes/no
Dizziness or fainting yes/no
Heart rhythm irregularity yes/no
Unusual shortness of breath yes/no
COPD/Asthma yes/no
Seizures yes/no
Arthritis, Joint problems yes/no
Back problems yes/no
Fractures yes/no
Chest pain at rest or with activity yes/no
Other useful information:
Health Appraisal: Cardiac History
Risk FactorDo you have this or are being treated for it?Please explain (attach records or pages if needed)Heart Diseaseyes/no
High Blood Pressure yes/no
Diabetes yes/no
High Cholesterol yes/no
Health Appraisal: Medications
Medications / Dosage & times per daySignature of Participant ______Date: ______
Signature of Parent or Guardian ______Date: ______
(if under 18)
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Sports Medicine