Fitness Club Membership Form

Stafford Fitness Center at Newell Field House

Primary Member:

First Name:
Last Name:
Mailing Address:
City:
State:
Zip:
Home Phone:
E-Mail:
Date of Birth:
Physician:
Emergency Contact Name:
Emergency Contact Phone:

Family Membership Information

If applying for a family membership, please provide information for each authorized family member.  Each family member must fill out separate PAR-Q forms. Family is 4 members. * Fifth member is an extra $25

Last Name: First Name: D.O.B.: Age:
Last Name: First Name: D.O.B.: Age:
Last Name: First Name: D.O.B.: Age:
Last Name*: First Name*: D.O.B.*: Age*:
Membership Fees
SLU Grad
Individual - Full Facilities
Family - Full Facilities
Family - Limited (no fitness center/tennis)
Community
Individual Adult - Full Facilities
Individual Adult - Limited (no fitness center/tennis)
Family - Full Facilities
Family - Limited (no fitness center/tennis)
Youth - Full Facilities (14 - 21)
Monthly
Seniors 62+ (proof of age required)
Senior - Full Facilities
Senior - Limited
St. Lawrence University Retirees

ST. LAWRENCE UNIVERSITY

Physical Activity Readiness Questionnaire (PAR-Q)

 

PAR-Q is designed to help you help yourself. Many health benefits are associated with regular exercise, and the completion of PAR-Q is a sensible first step to take if you are planning to increase the amount of physical activity in your life.


For most people, physical activity should not pose any problems or hazard. PAR-Q has been designed to identify the small number of adults for who physical activity might be inappropriate or those who should have medical advice concerning the type of activity most suitable for them.


Common sense is your best guide in answering these few questions. Please read them carefully and select YES or NO opposite the question if it applies to you. If yes, please explain.
1.  Has your doctor ever said you have heart trouble?
Yes,  
2.  Do you frequently have pains in your heart and chest?
Yes,  
3.  Do you often feel faint or have spells of severe dizziness?
Yes,  
4.  Has a doctor ever said your blood pressure was too high?
Yes,  
5.  Has your doctor ever told you that you have a bone or joint problem(s) such as arthritis that has been aggravated by exercise, or might be made worse with exercise?
Yes,  
6.  Is there a good physical reason, not mentioned here, why you should not follow an activity program even if you wanted to?
Yes,  
7.  Are you over age 60 and not accustomed to vigorous exercise?
Yes,  
8.  Do you suffer from any problems of the lower back, i.e., chronic pain, or numbness?
Yes,  
9.  Are you currently taking any medications?  If YES, please specify.
Yes,  
10. Do you currently have a disability or a communicable disease?  If YES, please specify.
Yes,  
If you answered NO to all questions above, it gives a general indication that you may participate in physical and aerobic fitness activities and/or fitness evaluation testing. The fact that you answered NO to the above questions is no guarantee that you will have a normal response to exercise. If you answered YES to any of the above questions, then you may need written permission from a physician before participating in physical and aerobic fitness activities and/or fitness evaluation testing at the St. Lawrence University fitness center.
By checking "I agree" you are certifying that all of the information provided about is accurate and that you understand the terms and conditions of your membership.