Start Strong with Newport Beach Athletic Club

MEMBERSHIP APPLICATION

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Your Name (required)

Last Name (required)

Email Address

Cell Phone

Business Phone

Home Phone

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Date of Birth

Choose Your Membership

—Please choose an option—Individual Men Membership - $120 per monthIndividual Jr.Men Membership - $65 per monthIndividual Women Membership - $60 per monthIndividual Jr.Women Membership - $35 per month

Mailing Address

City

State

—Please choose an option—AAAEAKALAPARASAZCACOCTDCDEFLGAGUHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPAPRRISCSDTNTXUTVAVIVTWAWIWVWY

Zip Code

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EMERGENCY INFORMATION

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First Name (required)

Last Name (required)

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Phone

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MEDICAL HISTORY AND HEALTH HABITS

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Today's Date

Date of Last Physical

Sex

—Please choose an option—MaleFemale

Age

Smoker

—Please choose an option—YesNo

How Long?

What is the present state of your health as you perceive it?

Physician

Phone

Answer the following to the best of your knowledge:

Have you consulted a doctor prior to joining this club?

—Please choose an option—YesNo

Has your doctor said you have heart trouble?

—Please choose an option—YesNo

Do you frequently suffer from pains in your chest?

—Please choose an option—YesNo
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Do you have high blood pressure?

—Please choose an option—YesNo

Do you have arthritis?

—Please choose an option—YesNo

Do you any problems that might be aggravated by exercise?

—Please choose an option—YesNo

Are you diabetic?

—Please choose an option—YesNo

Are you pregnant?

—Please choose an option—YesNo

Do you have any back problems?

—Please choose an option—YesNo

Do you have difficulty with physical exercise?

—Please choose an option—YesNo

Do you have a hernia or any other condition that may be aggravated by lifting weights?

—Please choose an option—YesNo

Have had surgery in the last 12 months?

—Please choose an option—YesNo

Are you taking any medications or drugs?

—Please choose an option—YesNo

Do you have a hernia or any other condition that may be aggravated by lifting weights?

—Please choose an option—YesNo

This form is intended for informational purposes only. It in no way represents acceptability to participate in any exercise activity. A consultation with your physician should be done before starting any exercise program.
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Your Initials

Adding your initials above and checking this box means you are accepting the Policies of the Newport Beach Athletic Club