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Select the Session you wish to register for: *
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Select Time: *
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Personal Information
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Name: *
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Address: *
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City: *
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Postal Code: *
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Home Phone: *
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Day Phone: *
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E-mail: *
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Birth Year:
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Medical Information
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Common Sense is your best guide when answering each of these questions.
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Please read the questions carefully and answer each one honestly.
Check the box if the answer is "YES".
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Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
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In the past month, have you had chest pain when you were not doing physical activity?
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Do you ever faint or do you lose your balance because of dizziness?
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Do you feel pain in your chest when you do physical activity?
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Do you have a bone or joint problem that could be made worse by a change in your physical activity?
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Is your doctor currently prescribing drugs (for example, water pills) for you blood pressure or heart condition?
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Do you know of any other reason why you should not do physical activity?
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Doctor's Note Required:
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If you answer YES to any of the above questions, you must obtain written medical clearance from a physician before participating in a Back on Track Bootcamp Fitness Program.
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Do you have a seizure disorder?
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Do you have diabetes?
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Do you have a seizure disorder?
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Emergency Contact: *
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Phone: *
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Method of Payment
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Write cheques to:
Back on Track Bootcamp Fitness.
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Mail or drop in person to
914 Byng Pl Winnipeg MB R3T0Y5
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Paypal
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Cheque (mailed or dropped off)
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Cash (dropped off)
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