Gym Membership Form

Thank you for signing up for the Gym! Please complete this membership form.

Questions for Gym Membership Form

1.

Name

The answer should be a text input.
2.

Address

The answer should be a text input.
3.

City

The answer should be a text input.
4.

State/Province

The answer should be a text input.
5.

Postal/Zipcode

The answer should be a number input.
6.

Home phone number

The answer should be a phone number.
7.

Cell phone number

The answer should be a phone number.
8.

Email address

The answer should be a email input.
9.

Do you declare a disability?

The answer should be a single choice:
  1. Yes
  2. No
10.

If yes, please specify

The answer should be a text input.
11.

Emergency contact details

12.

Contact person name

The answer should be a text input.
13.

Relationship

The answer should be a text input.
14.

Emergency contact number

The answer should be a phone number.
15.

Have you, for any reason, been unable to exercise in the past?

The answer should be a single choice:
  1. Yes
  2. No
16.

Has your physician ever advised you against exercising?

The answer should be a multiple choice:
  1. Yes
  2. No
17.

Have you ever suffered from any cardiac (heart) related illness?

The answer should be a single choice:
  1. Yes
  2. No
18.

Have you experienced chest pain while exercising?

The answer should be a single choice:
  1. Yes
  2. No
19.

Do you have high blood pressure?

The answer should be a single choice:
  1. Yes
  2. No
20.

Are you currently taking prescribed medication?

The answer should be a single choice:
  1. Yes
  2. No
21.

Signature

The answer should be a signature.
22.

Date

The answer should be a date input.

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