New Applicant Form

 

IMPORTANT - Read information and instructions carefully before completing each section

Part I - Veteran Personal Information
Name *
Name
Gender
PART II - ACTIVE DUTY SERVICE INFORMATION
NOTE: Please complete the information for period of active duty. We will ask for a copy of your DD214 or other separation papers for service verification.
Date Entered Into Military Service
Date Entered Into Military Service
Date Separated From Military Service
Date Separated From Military Service
Are you a Disabled Vetetan
PART III - Emergency Contact information
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Phone Number *
Emergency Contact Phone Number
Part iv - Fitness Evaluation
Are you currently or have you been a member of a club or gym before?
What level of exercise do you currently take part in today?
If you currently are exercising, what kind of exercise are you doing?
What are your current fitness goals?
Do you currently have a support system when it comes to attaining your fitness goals?
What are the best days for you to exercise?
What time of day is best for your schedule?
How far are your willing to travel, from work or home, to participate in the FMA program?
Part v - Health history
Do you now have or have you ever had
Do you now have or have you ever had pain, surgery or medical treatment for your
Do you now have or have had
Acknowledgement of Risk
I UNDERSTAND THAT A CERTAIN AMOUNT OF RISK OF INJURY AND IN EXTREME CASES DEATH IS INVOLVED IN ALL FITNESS TESTING. THEREFORE, IN ORDER TO INSURE MYSELF AGAINST MISHAP, I HAVE DETERMINED TO THE BEST OF MY ABILITY THAT I AM FREE OF ANY HEALTH PROBLEM THAT MAY INHIBIT MY ABILITY TO PARTICIPATE SAFELY, AND THAT I HAVE NO CURRENT MEDICAL RESTRICTIONS BARRING ME FROM PARTICIPATION, NOR AM I PRESENTLY BEING TREATED BY A PHYSICIAN OR PHYSICAL THERAPIST. I WILLINGLY ACCEPT THE RISK OF THE FITNESS PROGRAM IN ORDER TO GAIN THE KNOWLEDGE IT WILL PROVIDE ABOUT MY PRESENT FITNESS LEVEL.
I ACCEPT THE AKNOWLEDGEMENT OF THESE RISKS