New Memberships Print the following items or complete the online form below: Membership Application Access Contract Membership Terms & Conditions First Name: *Full Home Address: *Example: 202 N Wells, Edna, TX 77957Last Name: *Full Mailing Address: *Example: P.O Box 21, Edna, TX 77957Drivers Licenses or State ID No: *Please provide State, Type, & Number: TXID#111251747Date of Birth: *Example: 01/01/1977Preferred Contact Method: *EmailPhoneTextEmail: *You will receive a copy of the forms at this email, including notices.Mobile (Primary) Phone: *Example: 361-782-5772Preferred Time of Contact: *Morning – 11 AMNoon – 5 PMAfter 5 PMCurrent Employer: *Company Name; you may also be self-employed or unemployedSupervisor/Manager: Full name of immediate manager or supervisorFull Company Address: Physical Address, City, State, ZipCompany Phone: *###-###-####Primary Physician: *Full name of your current primary care doctorName of Medical Group/Practice: *Full Mailing Address: *Physician Address, Suite #, City, State, ZipClinic’s Phone: *###-###-####Emergency Contact #1: *Full NamePhone Number: A primary mobile numberRelationship: How are you related?Alternate Number: Another way to reach them?Emergency Contact #2: *Full NamePhone Number: A primary mobile numberRelationship: How are you related?Alternate Number: Another way to reach them?Date of your last Physical: *Goals & Fitness Concerns: Attending Physical Physician: *Primary Goal with Attending: Doctor RequiredWeight LossStrength TrainingBetter Self-ImageTraining for EventAre you currently enrolled in another exercise or workout program? *YesNoAre you currently pregnant? *YesNoPost-Partum less than 6 weeksAre you under any dietary restrictions? *Yes, Doctor RestrictedNoSelf-RestrictedDoctor suggest you are overweight? *YesNoUndiagnosed IssuesDo you currently smoke? *Yes, on occasionYes, heavilyNoNo, but previouslyHave you been diagnosed with orthopedic problems? *YesNoUndiagnosed Issuesbad back, weak knees, hip replacements, etcDiagnosed with any lung issues? *YesNoDiagnosed with High Blood Pressure? *YesNoNo, other kinds of BP issuesDiagnosed with Epilepsy or brain injury? *YesNoIncluding any abnormal EGG, previous seizures, or other types of blackouts.Diagnosed with Cardiovascular Problems? *YesNoIncluding any abnormal ECG, previous heart attacks, atherosclerosisDiagnosed with Diabetes? *YesNoDiagnosed with High Cholesterol? *YesNoDate of Lung Diagnosis: *If multiple dates, place the most recent diagnosis date.Date of BP Diagnosis: *If multiple dates, place the most recent diagnosis date.Date of Epilepsy Diagnosis: *If multiple dates, place the most recent diagnosis date.Date of Cardio Diagnosis: *If multiple dates, place the most recent diagnosis date.Date of Diabetes Diagnosis: *If multiple dates, place the most recent diagnosis date.Date of High Cholesterol Diagnosis: *If multiple dates, place the most recent diagnosis date.Are you currently taking supplements or medications? *Yes BothSupplements OnlyMedication OnlyNoneSupplements/Medication Details: Please provide the amount and what you are taking.Other Medical Conditions: Please provide any diagnosis not previously mentioned that might be of concern with your workout routines.General Agreements: *All information is true and correct & submitting online Member Application is the first step to joining Total Body Gym fitness center.I understand that I have to go through orientation before I can begin my membership access.I have an tour orientation scheduled already in the coming two weeks.I understand that have consulted with outside doctors or a physician on how fitness can affect my health.I have reviewed & agree to the following: *Terms & Conditions of MembershipTerms of Access to Total Body GymGym FeesToday’s Date: *CommentSubmit
