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AYO-CHI CLASS - INFORMATIONAL SIGN UP SHEET
complete an informational sign-up sheet...
Age (in years):
Height (in inches):
Weight ( in lbs. ):
I AM INTERESTED IN ATTENDING CLASSES AT THE FOLLOWING LOCATIONS
SUNY ORANGE COMMUNITY COLLEGE
MINERALS SPA AND RESORT
I WANT TO SET UP A CLASS AT MY LOCATION
UNION AVENUE "Y" FITNESS CENTER
Please choose all the statements below that apply to your personal health and fitness. Please provide any
additional information that might be necessary for us to know prior to your attendance in the space provided.
We take every precaution in maintaining your health and safety, please help us by giving us proper information.
I WANT TO LOSE WEIGHT
I WANT TO GAIN MUSCLE
I WANT TO BE MORE PHYSICALLY FIT
I WANT TO STICK TO MY EXERCISE
I WANT TO LEARN HOW TO EAT PROPERLY
MY GOALS ARE DIFFERENT THAN THESE
We all have different goals and it is important
that we reach those specific goals. Please
choose the goal (or goals) that best represent
what you are looking to achieve.
If your goals are different than those listed,
please enter your goals in the ISSUES /
CHOOSE ALL STATEMENTS THAT APPLY TO YOU
Additional Health Issues / Comments:
Do you have a heart condition ?
Do you have chest pain when physically active?
Are you diabetic or hypoglycemic?
Do you have a bone or joint problem that limits activity?
Do you lose your balance because of dizziness ?
Have you had chest pain when not active?
Are you on high blood pressure / heart medications?
Is there any reason why you shouldn't exercise?
None of these statements apply to me...
I have given all my known medical information requested on this form and I
have been cleared by my physician to participate in this program. Any
participation not cleared by my physician, based on my health status, is done
so at my own discretion and I waive any rights regarding possible damages.
DISCOVER YOUR ENERGY