Fitness Information

Zest For Life Program Enrollment Form

Please Note: All fields are required.

Full Name:
Age:
Gender:
Office Phone:
NSU Email Address:
Emergency Contact Person:
Emergency Contact Phone:

University Affiliation:
University Dept. or Center:

Do you currently have any of the following conditions or behaviors:
	Do you feel pain in your chest when you do physical activity?
	Have you ever been told by a doctor that you have bone, joint, or muscle problems that could be made worse by physical activity?
	Do you have a diagnosed illness that could be made worse by physical activity?
	Do you have high Cholesterol; >200?
	Do you currently have high blood pressure?
	Do you currently smoke?
	Do you currently drink more than one alcoholic beverage per day?
	Do you know of any medical reason as to why you should not do physical activity?

Fitness Participation Agreement

I have voluntarily chosen to participate in fitness activities offered by the office of Campus Recreation at Nova Southeastern University. I have answered the questions above to the best of my ability and affirm that my physical condition is good and I have no known conditions that would prevent me from participation. I acknowledge that participation is at my own pace and comfort level and that I may discontinue my participation at any time. Furthermore, I agree to self-determine my exertion through good judgement and to discontinue any activity that exceeds my personal limitations. I understand that by signing this agreement that I hereby waive and release Nova Southeastern University, its president, Board of Trustees, staff, and all relevant employees in any way from liabilities or demands as a result of injury, loss, or adverse health conditions as a result of my participation. I affirm that I have read and understand this document and I wish to participate in fitness activities.