HealthStyle Fitness: Cincinnati FitKids: FitKids Registration

physical education, students, children, kids, Cincinnati, Ohio, FitKids Boot Camp

FitKids Registration

REGISTRATION

You now have 2 options:

A. You can print this form and send it in with payment by mail

B. Register Online

Fill out the online form below to register via internet. Click on Submit to go to the payment page.

Payment Page: Pay via Paypal. Choose your class and finish your online registration. A PayPal account is not required to pay via PayPal. Monthly Payment Plans Are Available.

NOTE: Spaces fill quickly for this unique experience. We cannot guarantee your space until we have received registration & payment.

If paying by check, please make check out to:
HealthStyle Fitness, INC
4325-B Red Bank Road
Cincinnati, OH 45227
(513) 407-4665

Registration Form
Upon completion of your registration & payment you will be directed to the FitKids Welcome Page with information on your child's first session.
Personal Information
Child's Name
Parent's Name
Address
City
State / ZIP	/
Profession
Country
Date of Birth	(mm/dd/yyyy)
Phone (Cell)
Work Number
Fax Number
Email Address
Emergency Contact Information:
Name
Phone Number

Self Assessment & Additional Information
I rate my child's current activity level as a (1-10), ten being high.
I was referred by:
How did you hear about us?:
Please specify publication / website / friend or other referral:
This is my first time working with HealthStyle Fitness or FitKids:	Yes \| No

Age Group and Payment Information
What group is your child joining?
Choose your child's frequency and cost.
Form of payment:

Your Child's Medical History
1. Is your child allergic to any medication (aspirin, penicillin, sulfa, etc.)?
Please List Medications:
2. Does your child have a seizure disorder (epilepsy)?
3. Does your child have have diabetes?
List Medications:
4. Has your child ever been found to be anemic (low blood count)?
5. Does your child have have High Blood Pressure (hypertension)?
List Medications:
6. Does your child have or have you ever had the following diseases?
Heart Disease:
Lung Disease:
Kidney Disease:
Liver Disease:
7. Does your child have asthma?
List Medications:
8. Has your child ever had a severe neck injury? Describe:
9. Has your child ever been knocked out? Describe:
10. Has your child had a broken bone or fracture in the past 2 years? Describe:
11. Does your child have other physical conditions which cause pain? Describe:
12. What physical activities does your child enjoy most? (Sports, Indoor/Outdoor Games, Bike Riding, etc.)

Release

NOTICE: It is wise to seek your doctors advice before beginning any health/fitness/nutrition program!

This release is entered into between the undersigned and HealthStyle Fitness, Inc., its officers, subsidiaries, affiliates, and executors in addition to the City of Cincinnati.

The purpose of Cincinnati FitKids is to provide a fun environment for kids to receive organzied play and activity to enhance their self-esteem, fitness, mental, emotional and physical outlook.

The undersigned hereby acknowledge that the following was explained to me and/or agree to the following:

1. Acknowledges that Brian Calkins, or any member of his staff, is not a physician and is not trained in any way to provide medical diagnosis, medical treatment, or any other type of medical advice.

The Undersigned agrees that this is the full agreement between the parties, that HealthStyle Fitness, Inc, including Brian Calkins, his staff, nor anyone else has not verbally contradicted any of the terms of this release and that the undersigned has entered into this agreement free and voluntarily without force or coercion.

Customer/client agrees to confidentiality with respect to the Cincinnati FitKids and all services provided by HealthStyle Fitness, Inc. The undersigned agrees to refrain from disclosing, directly or indirectly, any and all aspects of the FitKids.

I hereby voluntarily consent to fitness programs from HealthStyle Fitness, Inc. I understand that my child may stop at any time because of feelings of fatigue or discomfort or any other personal reason.

Further, we agree to assume the risk of any exercise and HealthStyle Fitness assumes no liability for injury or damages arising from my participation in any fitness program with HealthStyle Fitness. All fitness activities present certain inherent risks and hazards which I have considered and which I assume. I agree to hold harmless HealthStyle Fitness and its staff from any and all responsibility, claims, suits, losses, or related causes of action resulting from my participation in any HealthStyle Fitness program, including, but not limited to, injuries arising from fitness activities.

Agreement and Signature

I agree to all Terms and Conditions listed above

Electronic Signature

Date (MM/DD/YYYY)

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