Register

First Name:

Last Name:

Sex:

Male Female

Age:

Email:

Postal or Street Address:

City:

State:

Zip Code (5 digits):

Home Phone: Cell Phone: Work Phone:

Family/Other Physician:

Emergency Contact:
Name, address and phone number of someone we can contact in case of an emergency. Signing here can be used as a digital signature.

Question 1:
Are you aware of any physical reasons why you should not follow a physical activity program even if you wanted to?

Yes No

Question 2:
Has a doctor instructed you not to participate in an activity program even if you wanted to?

Yes No

Consent For Classes and Training:
I, the undersigned applicant for and in consideration of the benefit to be derived by participation in any of the Wellness programs offered by NCMH Wellness Center (Body Sculpting, Breather's Choice, Cardio Mix & Sculpt, Chair Aerobics, CPR, First Aid, HeartFIT, Senior Fitness, Yoga-Gentle, Yoga Pilates Mix and Zumba) do hereby release and forever discharge NCMH, its agents, industry, illness or sickness which may result from participation in the Wellness classes or programs elected, and do hereby further agree to indemnify and hold harmless NCMH, its agents, servants and employees from any and all liability in such regard. *need physician referral

Total Due: $0

Health & Wellness

Register

William Joseph Hollins, II

Charles R. Hubbard

H. Keith Riddle, Jr.