| Contact Information |
| First Name: |
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| Last Name: |
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Address:
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| City: |
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| Zip Code: |
(5 digits) |
| Phone: |
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| E-Mail: |
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| Date of Birth:: |
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| How Did You Hear About Us?: |
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Emergency Contact
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| Name: |
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| Relationship: |
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| Phone: |
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My GO Fit Program
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| Class Dates, Times and Locations: |
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Veteran |
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Newbie (New to GO Fit)
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Please Note: If you are a returning veteran and your Health History has not changed, there is no need to fill it out again. Please make sure we have it updated in 2008.
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Health History(Please check all that apply and answer any questions that pertain to you.) **GO Fit recommends consulting with a physician prior to participating in our fitness program.
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I am allergic to certain medications.
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| Explain: |
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I am currently taking prescription medication. |
| Explain: |
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I have been told by a doctor that I am anemic.
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| When and What Treatment: |
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I have had or currently have high blood pressure. |
| List any medication: |
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I have a seizure disorder (epilepsy). |
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I have been treated for diabetes. |
| List any medications: |
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I have been told by a doctor that I have asthma. |
| List any medication: |
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I have been "knocked out" or become unconscious in the past three years? |
| Describe and give dates: |
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I have had a neck injury involving bones, nerves, or disks that disabled me for a week or longer. |
| Explain: |
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I have had a broken bone (fracture) in the past two years? |
| Explain: |
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I have had a shoulder injury in the past two years that left me disabled for a week or longer. |
| Explain: |
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I have injured my back. |
| Type of injury/dates: |
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I have back pain (occasionally) |
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I have back pain (frequently) |
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I have back pain (with vigorous exercise) |
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I have back pain (with heavy lifting) |
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I have injured my knee in the last two years. |
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I have had knee surgery. |
| Explain: |
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I have had a severe ankle sprain in the last two years. |
| Please tell us of any other conditions we should be aware of (i.e. ulcers, pregnancy, food or insect allergies, tendinitis, etc.): |
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| Other Information |
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The questions on this form have been answered completely and truthfully to the best of my knowledge. |
Payment
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How will you be paying?
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Cash |
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Gift Certificate |
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Check
(Please make checks out to GO Fit and mail to 7313 Brecourt Manor Way, Austin, TX 78739. If within 5 days of start date, bring to first day of class.)
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PayPal using e-mail address info@gofitaustin.com
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$150 (One month SPECIAL)
$250 (Two month SPECIAL)
$25 - "Team GO Fit" - Turkey Trot (does not include race registration)
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I am ready to
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GET OUTSIDE and GET FIT with GO FIT!
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