Welcome, New Student!

Name *

First Name

Last Name

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Interest *

Duet

Private Classes

Group Classes

Combination

Do you have any of the following conditions?

Please select all that apply to your medical history

Bulging or herniated disk(s)

Joint replacement

Spinal fusion

History of heart attack or stroke

Osteoporosis

Significant undiagnosed pain

Are you pregnant?

Yes

No

Have you given birth within the past 6 months?

Yes

No

If "Yes" to either of the above, has your doctor cleared you for exercise at this time?

Yes

No

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