First Name: *  (Primary Contact)
Last Name: *  (Primary Contact)
Language:
Birthdate:
Gender:
Address: *
City: *
Country: *
Province: *
Postal Code: *
Residency:
Phone: *  (ex: XXXXXXXXXX)
Health Notes: *
Emergency Contact: *
Emergency Phone: *  (ex: XXXXXXXXXX)

Par-Q Required for Fitness Centre - On File for the Year - If YES, provide Par Q+, if YES is answered must provide Physician Physical Readiness Clearance before coming to Fitness Centre or first day of class (Perscription to Get Active = Physician Clearance): *

     
Email: *
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Verify Password: *  
Password Requirements: Between 8-16 characters, 1 alphabetic, 1 numeric, 1 special character (!@#^*-=), no spaces
Family Members: