Registration Form 1

Mindful Strides Training Registration Form - page 2

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Your Address *

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City

State

Zip Code

Country

Please read carefully - check any boxes that apply to you. If none apply, check the bottom option. If any apply, please contact us prior to enrollment. *

Your doctor has said that you have a heart condition AND that you should only do physical activity recommended by a doctor. Feel pain in your chest when you do physical activity. In the past month, had chest pain when not doing physical activity. Lost balance because of dizziness or have lost consciousness in the past. A bone or joint problem that could be made worse by a change in your physical activity. Doctor currently prescribes drugs for blood pressure or a heart condition. Any other reason that you should not do physical activity. None of the above apply to me - if this changes in the future I will inform Mindful Strides Training right away.

Do you have any past injuries / health complications that we should be aware of? *

Do you have any past experience in the class / training that you selected - if so, what is it and what are your main goals? *

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