ENTER INFO
How did you learn about the program?*
Date
Name*
Mobile number*
Email address*
Zip Code*
Which wellness programs are important to you?
Emotional
Environmental
Financial
Intellectual
Occupational
Physical
Social
Spiritual
What is your classification?
Pittsburgh Yards Resident/Business
Employee (Area Business Owner/Employee)
Atlanta Public Schools
Adair Park Resident
Pittsburgh Resident
Capitol View Resident
Capitol View Manor Resident
Neighboring Community
Household status
Single
Spouse/Partner
Child(ren)
Pet(s)
Have you worked out consistently (3 to 5 times per week) for 3 yrs?
Yes
No
Never got close
Is your job physical demanding or do you spend a lot of time seated?
Active
Seated
Will you use the Atlanta Beltline to access Pittsburgh Yards?
Yes
No
50/50
Are you eating 3 meals per day?
Yes
No
Are you anemic?
Yes
No
Do you drink wine/liquor? If yes, how often.
1 to 3 glasses a week
4 to 7 glasses a week
8 to 11 glasses a week
12 or more glasses a week
N/A
What are you looking to achieve fron the Fit23 Program?*
Stay Active/Reactive Physically
Decrease Body Fat
Financial Independence
Group Mental Health Therapy
Increase Endurance /Stamina
Increase Mobility
Manage Chronic Conditions
Manage Stress
Nutritional Guidance /Programming
Peace of Mind/Emotions
Spiritual Wellness
Social Anxieties
Is there anything specific stopping you from starting a wellness program?*
Which fitness classes would you be interested in participating in?
Bootcamp Training
Boxing
CrossFit
Court Sports
Dance (Hip Hop, Zumba,Chair,Modern,African)
Field Sports (Shot Put,Javelin,High,Long & Triple Jump)
Hiking / Mountain Climbing
HITT Circuit
Jogging / Running
Martial Arts Training (Karate,Jujitsu,Grapple,Wrestling)
Soccer
Speed /Power Walking
Step Class
Cycling Class (Indoor and Outdoor)
Plyometrics
Pole Dancing
Track Training (100,200,400,hurdles)
Weight Training
Yoga / Tai Chi / Pilates
Are you 17yrs old or younger? If so, what is your age?*
emergency contact name*
emergency contact phone*
emergency contact relationship*