South Park Fitness Questionnaire This form will be printed by our staff. Name* First Last Email* Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Age*Date of Birth* Date Format: MM slash DD slash YYYY Emergency Contact Name* First Last Emergency Contact Phone Number*We would love to know how you found us:* Walking By Instagram Local South Park Shop Referral Yelp Google Other Please check yes or no below. I am interested in scheduling a time with a Personal Trainer to acquaint me with basic exercises and equipment.* yes no We want to make sure you are successful in accomplishing your health & fitness goals. Our trainers are more than happy to help acquaint you with basic exercises and offer support and guidance. Please check yes or no below.I am interested in the Jump Start Program.* yes no The Jump Start Program is 3 sessions to teach you how to correctly and effectively complete your workouts yielding the results you want. It also includes a written exercise program specifically tailored to your fitness goals.Do you have injuries or health conditions that may limit exercise?* I have NO injuries or health conditions that may limit exercise. YES I have injuries or health conditions that may limit exercise and they are listed below. My injuries or current physical limitations are:We can schedule a time with a Personal Trainer to help you rehabilitate your injuries through a personalized corrective strengthening and stretching protocol.* Yes, I am interested in scheduling a time with a Personal Trainer to help rehabilitate my injuries. No, I am not currently interested in scheduling a time with a Personal Trainer to help rehabilitate my injures. Cancellation Policy: We require a 7 day notice VIA EMAIL ONLY for any membership cancellation to ensure that you will not be charged. Please read and check below.* Yes, I have read and understand the cancellation policy. Cell Phone Policy: As a courtesy to others, please take your calls outside the gym.* Yes, I understand the take my calls outside the gym policy. **NO SIGNATURE REQUIRED YET. SIGN ONLY WITH STAFF.I will sign this document upon my first visit to South Park Fitness. This document will be printed for me on my arrival. My printed name as I would like to be called.* First Last For example if your legal name is Elizabeth but everyone calls you Lizzie. Please state here. Thank You!What is the color of the ocean?*This is a Bot Blocking question. You must answer the question correctly to submit this form.EmailThis field is for validation purposes and should be left unchanged.