Name:______Sex: ______DOB:______
Phone: ______Email:______
Address (Street, City Zip):______
Insurance Company:______Insurance ID Number:______
Employer:______Insured Name & address if different from above: ______
Program name, time & location you are pre-registering for
Class Name:______Time: _____ Location: ______Date you want to start class:______
Patient Responsibility (For participants with Blue Shield of Northeastern New York Insurance)
I am registering for the above Program, utilizing the ‘wellness’ benefit under my insurance plan. I understand FitnessProfessionalsOnDemand will be billing my Insurance Company for the entire program (all classes in this program) to be applied against my ‘wellness’ benefit.
I understand that I may be responsible for payment for services if it is determined by my insurance company to be non-covered services if I have an insurance plan without wellness benefits or if my insurance contract has terminated. I understand that under these circumstances services I am financially responsible for payment of these non-covered services.
Signature: Date:
Waiver*(For all persons pre-registering)
I do not have any medical problems that would put me at medical or physical risk from participating in this class. If there is any doubt or if I have any chronic or acute medical problems or if I am pregnant I have checked with my doctors and obtained a medical release and I have given my instructor a copy of this medical release.
I have read and honestly answered (checked yes or no) the Physical Activity Readiness Questionnaire below.
Signature: Date:
Physical Activity Readiness Questionnaire (PAR-Q) and You Questionnaire * If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor. Common sense is your best guide when you answer these questions. (*ACSM’s Health/Fitness Facility Standards and Guidelines, 1997 by American College of Sports Medicine)
YES NO (please enter yes or no below for each question)
Has your doctor ever said that you have a heart condition and that you should only do physical activity
recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?
If you answered YES to one or more questions Talk to your doctor by phone or in person BEFORE you start becoming much more physically active. If you answered NO to all PAR-Q questions, you can be reasonably sure that you can start becoming much more physically active – begin slowly and build up gradually