Please note: If you are under the age of 18, you will need to complete our paper application with a signature of a parent or guardian.

Start Date *

Name

Date of Birth *

Email *

Phone

Street Address *

City *

State * Select Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Zip *

Primary Contact Name *

Primary Contact Phone *

Secondary Contact Name *

Secondary Contact Phone *

Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? Yes No

Do you feel pain in your chest when you perform physical activity? Yes No

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

Do you lose your balance because of dizziness or do you ever lose consciousness? Yes No

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

Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? Yes No

Do you know of any other reason why you should not engage in physical activity? Yes No

If you have answered "Yes" to one or more of the above questions, consult your physician before engaging in physical activity. Tell your physician which questions you answered "Yes" to. During your medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.

Height

Weight (approximate)

Do you have any limitations that restrict movement in any way (Lower back pain, knee pain, results of an injury or surgery, etc.)? If yes, please explain.

Do you have Coronary Artery Disease? Yes No

Do you have Diabetes? Yes No

Do you have Hypertension? Yes No

Significant medical history

Do you smoke? Yes No

If yes, how many packs/week

How many sessions per week can you realistically fit into your schedule?

Would these sessions ever be on consecutive (back-to-back) days?

How much time per session to you wish to spend?

Have you participated in an exercise program in the past 5 years?

Do you currently participate in any type of physical activity? If yes, please explain. If no, why did you discontinue?

Please explain what you expect to accomplish. Include your short-term and long-term goals.

Please express any comments or concerns that you think would be helpful to us in the design of your program

If our staff recommends more sessions and/or time per week for you to meet your goals, are you willing to commit to the suggested program? Yes No

Prime/Silver Sneakers ID

Please select membership level Adult 1 Month Adult 3 Months Adult 6 Months Adult 1 Year Family 1 Month Family 3 Months Family 6 Months Family 1 Year

Are also interested in purchasing a 24-hour card for unlimited access to the gym for a 1-time fee of $25.00? Yes No

Agreement and release of liability for WellSpan Results Therapy & Fitness

The undersigned knowledge that he/she is voluntarily participating in an exercise/fitness activity and the use of exercise equipment and machinery. I agree that there is inherent risk in any such activity and I agree to release Results Therapy and Fitness, its officers, agents, representatives, and employees from any and all liability, damages, or expense which I have or may have against Results Therapy and Fitness arising from or relating to any accident or injury I may sustain while engaging in this activity.

I further understand and have been informed of the need for a physician’s approval for my participation in an exercise/fitness activity or in the use of exercise equipment and machinery. I also acknowledge that it has been recommended that I have at least yearly physician examinations and consultations with my physician as to physical activity, exercise, and the use of exercise and training equipment. I acknowledge that I have either had a physical examination and have been giving my physician’s permission to participate, or that I have decided to participate in this activity and use of equipment and machinery without approval of my physician. I agree to assume all responsibility for my participation and utilization of equipment and machinery in my activities.

I understand that I have read the entire agreement and release of liability and understand its meaning and agree to be bound by its terms