STRONG Nation Group Fitness Classes Registration Participant InformationParticipant Name First Last Participant Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Participant Cell Number(Required)Participant's Gender Participant's Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Parent/Guardian Information - if participant under 18 years oldParent/Guardian Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent Email Address Parent Cell NumberEmergency Contact Name - All Participants to Complete(Required) First Last Emergency Contact Relationship(Required) Emergency Contact Phone(Required)Par-Q and Medical HistoryPhysical Activity Readiness Questionnaire1. Has a doctor ever said you/your child has a heart condition and that you/he/she should only perform physical activity recommended by a doctor? Yes No 2. Do you/your child feel pain in your/his/her chest when performing physical activity? Yes No 3. In the past month, have you /your child had chest pain when NOT performing physical activity? Yes No 4. Do you/your child lose your/his/her balance because of dizziness or do you/he/she ever lose consciousness? Yes No 5. Do you /your child have a bone or joint problem that could be made worse by a change in your/his/her physical activity? Yes No 6. Is your/your child’s doctor currently prescribing any medication for blood pressure or a heart condition? Yes No 7. Do you know of any reason why you/your child should not engage in physical activity? Yes No 10. Has a medical doctor ever diagnosed you/your child with a chronic disease? If yes, please explain.WaiverI understand that I am purchasing group training sessions for myself or my child and must read, agree to and sign this agreement where I assume the risks for participation, waive of liability, and agree to the Total Strength Fitness policies and procedures. I understand that the program is voluntary and that a Certified Personal Trainer will lead Strong Nation (by Zumba) fitness classes, which includes high intensity exercises where modifications are demonstrated and encouraged. I represent that I will complete the PAR-Q and any other health history form accurately and completely on behalf of myself or my child including disclosure of any exercise limitations I am aware of or have been informed of by my/my child’s doctor. During the program if my/my child’s condition or medical limitations should change, I will notify the Trainer. I understand that it is recommended that i/my child have a yearly physical or more frequent physical examination and consultation with my/his/her physician as to physical activity and diet so I am aware of what is appropriate for me/my child. I acknowledge that I/my child either have had a physical exam and has been given a physician’s permission to participate or I have decided to allow myself/my child to participate without approval of a physician. I understand that a Trainer will review my my child’s PAR-Q and any other health history form but that a Trainer is not a physician and cannot replace the advice and expertise of a qualified physician. I understand that I have the complete right to stop or decrease my/my child’s exercise at any time during a session and that it is my/ my child’s obligation to inform the Trainer of any symptoms such as fatigue, shortness of breath or chest discomfort. I realize that participation in an exercise training program includes but is not limited to exercising, use of exercise equipment and strenuous exertion (such as strength training or high intensity aerobic activity) which will increase heart rate and body temperature. I understand that exercise involves certain risks, including but not limited to, serious neck and spinal injuries resulting in complete or partial paralysis, heart attack, stroke or even death. Also, injuries could occur to bones, joints or muscles. Slips, falls, and unintended loss of balance could result in muscular, neurological, orthopedic or other bodily injury. I understand that part of the risk involved in undertaking any activity or program is relative to my/my child’s own state of fitness or health (physical, mental, or emotional) and to the awareness, care and skill which I/my child conducts himself/herself in that activity or program. I understand that proper form of any exercise (as described and/or demonstrated by Trainer) performed by me/my child is a necessary and essential component of an exercise program. Knowing the material risks and knowing and reasonably anticipating that other injuries are a possibility, I hereby expressly assume all of the delineated risks of injury, all other possible risk of injury, and even risk of possible death, which could occur by reason of my/my child’s participation. I do hereby waive, release and forever discharge Total Strength Fitness and the STRONG Nation (by Zumba) fitness program from any and all responsibilities or liability for any present and future injuries or damages resulting or arising from my/my child’s participation in any activities including but not limited to exercise, group training, or use of the equipment used within STRONG Nation (by Zumba) Group Fitness classes. I also understand that STRONG Nation Group Fitness classes may take place in a facility not owned by Total Strength Fitness, and this facility may have its own equipment not used by STRONG Nation. I understand that I/my child will not use any equipment not included in the STRONG Nation Group Fitness classes during the time that I/he/she am/is participating in these group fitness classes. I AGREE AND UNDERSTAND.(Required) Initial Here.Personal Training Policies and Procedures1. STRONG Nation group fitness classes are purchased upfront and in their entirety. 2. Total Strength Fitness does not offer refunds for unused sessions by client. 3. PAR-Q and Waiver, and Agreement must be completed, signed, and on file prior to the beginning of the first session. 4. Training sessions will begin promptly at the time specified by Total Strength Fitness and end 60 minutes, or other agreed upon amount of time, from that specified time. I AGREE AND UNDERSTAND(Required) Initial HereParent/Guardian Agreement - if Participant is under 18 years oldI declare that I have read, understand and agree to the contents of this Total Athlete Training Agreement in its entirety. I understand that the Assumption of Risk, Waiver of Liability, and Total Athlete Training Policies and Procedures are intended to be as broad and inclusive as permitted by the State of Minnesota and agree that if any portion is held invalid, the remainder will continue in full force and effect. Signature(Required)Please provide signature via touchscreen, touchpad or mouse.PaymentOnce you click submit, you will be directed to PayPal for payment. Payment will be accepted via PayPal funds, eCheck or Credit Card. If you choose to pay by check, instructions will be provided on where to send your payment.Total Registration Fees - See Options in Drop Down(Required)3 Class/Week2 Classes/Week1 Class/Week1 ClassPayment MethodPayPalCashPhoneThis field is for validation purposes and should be left unchanged.