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2. Today's Date*
   Today's Date
3. Contact:
   (314) 963-5600
5. First Name*
6. Last Name*
8. Parent/Guardian (if under 18)
9. Parent/Guardian (if under 18)
11. Best Phone #*
12. Date of Birth*
14. Email
16. Best way to reach you?*

    1. Phone
    2. Email
20. Please complete the following information so we can place you with the trainer who will best meet your needs.
22. When do you prefer the training sessions to be? Check all that apply.

    1. Morning
    2. Afternoon

    1. Evening
    2. Weekends

    1. Anytime
24. Preferred Trainer

    1. Brittyne Fitzgerald
    2. Zach Cayer
    3. Tommy Koelling
    4. No Preference
26. Please list any health concerns you have (optional):
28. Briefly describe your health and fitness goals:
32. Physical Activity Readiness Questionnaire (PAR-Q)
34. Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommend by a doctor?*

    1. Yes
    2. No
36. Do you feel pain in your chest when you perform physical activity?*

    1. Yes
    2. No
38. In the past month, have you had chest pain when you were not performing any physical activity?*

    1. Yes
    2. No
40. Do you lose your balance because of dizziness or do you ever lose consciousness?*

    1. Yes
    2. No
42. Do you have a bone or joint problem that could be made worse by a change in your physical activity?*

    1. Yes
    2. No
44. Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?*

    1. Yes
    2. No
46. Do you know of any other reason why you should not engage in physical activity?*

    1. Yes
    2. No
50. General & Medical Questionnaire
52. Does your occupation require extended periods of sitting?*

    1. Yes
    2. No
54. Do you partake in any regular recreational activities or hobbies (fitness center exercise, golf, tennis, skiing, hiking, gardening, etc?) If yes, please explain below:*

    1. Yes
    2. No
56. Explanation to the above question:
58. Has a medical doctor every diagnosed you with a chronic disease (coronary heart disease, diabetes, hypertension, high cholesterol, other) If yes, please list below:*

    1. Yes
    2. No
60. Explanation to the above question:
62. Please provide any other details that may help us get to know you:
64. Thank you for completing our inquiry form, we will follow up very soon. If you have questions, please contact our Recreation Superintendent at (314) 963-5600 or kearbeyk@webstergrovesmo.gov.
Leave This Blank:


66. 1. Receive an email copy of this form.
67. Email address

    This field is not part of the form submission.

68. Submit

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