YMCA Fitness Assessment Form

First Name

Last Name

Email Address:

Phone Number:

What are your goals? Please check all that apply:

Weight Loss

Strength

Sports Performance

Rehab/Recovery

Flexibility/Mobility

Mental Wellness

Other…

Do you have any medical conditions or injuries that could affect your ability to exercise?

Yes, please explain:

What gym services are you interested in? Please check all that apply.

Strength Machines

Cardio Machines

Personal Training

Group Exercise

Would you be interested in any of the following services for yourself or your family?

Sports (Youth, Adults, Special Needs, etc.)

Teen Programs (Youth & Government, Teen Camp)

Education (Preschool, Afterschool, STEM)

Swim Lessons

Child Watch

Special Events (Turkey Trot, Healthy Kids Day, Community Events etc.)

Summer Camp

Adventure Guides

Would you be interested in any of the following Community Health programs for yourself or your family?

Diabetes Prevention (year-long program to learn healthy habits in small group sessions)

Get Up and Go (10-week weight management program for children and their parents giving the tools to develop and maintain healthy habits)

LIVESTRONG (12-week physical activity program for cancer survivors)

FIT for Health (free 11-week healthy lifestyle program for parents and their children to learn fun physical activities, healthy habits, calorie goals and self-monitoring, as well as positive parenting styles and tips)

Blood-Pressure Self-Monitoring Program (four-month program focuses on regulated home self-monitoring of one’s blood pressure)

Kamp K’aana (introduces children, ages 10-14, to the tools they need to learn and love a healthy lifestyle, while offering the fun of an overnight summer camp experience!)

Which days of the week are you available? Please check all that apply.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Which times of day are you available? Please check all that apply.

5:30 AM-9:30 AM

9:30 AM-1:30 PM

1:30 PM - 5:30 PM

5:30 PM - 9:30 PM