PDF Version of Questionnaire
Fitness
Level Questionnaire and Goals / Waiver of Liability
Last Name
–_______________________ First Name____________________ Age_____ Sex -
M / F
City -______________
St______ Phone (H) - _____________ (Cell) -_________________
Email
Address _____________________
Current Physical
Condition and Goals
|
Height |
Beginning |
Goal |
|
Weight |
|
|
|
Pushups* |
|
|
|
Situps * |
|
|
|
Pullups |
|
|
|
1
mile run |
|
|
|
1.5mile run |
|
|
|
2
mile run |
|
|
|
3
mile run |
|
|
|
300m
or 400m run |
|
|
|
500yd swim |
|
|
(*maximum
or in 1 to 2 minutes max time)
Other
Goals - _______________________________________________________________________
__________________________________________________________________________________
Join the
military, fire / police department, government agency - By what date___________
If YES -
Which branch of service or agency-
__________________________________________________
History
1. Have
you had or do you have any disorders mentioned below? (Y/N)
____Heart
Disease ____Chest
Pains
IF
YES - PLEASE ELABORATE:
____Heart Problems ___Back Trouble
____________________________
____Anemia
__
Asthma
___________________________
____Diabetes
__
Hernia
__________________________
____Joint
Pain
___Epilepsy
____Fainting Spells ___High Blood
Pressure
Other_________________________________________________________________________________
2. Any
history of hospitalizations, operations and/or serious
injuries?_______________________________
3. Are you currently taking any medications? Please provide
specifics._____________________________
By signing
I am verifying that the above information is accurate and agree to waive any
liability, claims, actions or damage of any kind resulting in the participation
in the free pre-military training program taught by my trainer,
__________________ , and Stew Smith or the Heroes of Tomorrow Organization.
I,
_____________________________ assume any
risks in this program.
signature (if minor - must be signed by parent)
