Select Fitness Class And Time:

Studio: Maple Ridge Coquitlam

Bounce Back - Core and Body Strength (4 weeks post-partum + with pre-walkers / Class time and day:
NONE None Apr Coquitlam Fri 9:30

Stroll & Strengthen - Outdoor total body workout (6 weeks post-partum+ with 1 or 2 stroller aged children/ Class time and day: None Coquitlam Apr-Jun Fri 12:30 JULY PLEASE REGISTER ON THE SUMMER PAGE **A mat is recommended for the outdoor fitness class. Please bring your own, or order our water resistant mat below.

Are you taking advantage of the "bring 5 friends and come for free" offer? (See left for details). If so, please list the friends who are signing up with you. (Please note that they must also list you on the referral section of their form.)

Personal Information:

Attendee's Name (adult):
Date of Birth:

Address: City:
PC: Email:
Phone:

Child Attending: (first and last)
Birthdate:

2nd child attending:
Birthdate:

Are you a:

Returning Client
New Client-

If new, how did you hear about us?

Print Ad Event Internet

Friend - Frient / Event Name:

MEDICAL INFORMATION: (Please answer yes or no.)

1.Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Yes No
2. Do you feel pain in your chest when you do physical activity?
Yes No
3. In the past month, have you had chest pain when you were not doing physical activity?
Yes No
4.Do you lose your balance because of dizziness, or do you ever lose consciousness? Yes No
5. Do you have a bone or joint problem (back, knee, hip, etc.) which would worsen by an increase of physical activity? Yes No
6. Are you currently expecting a baby? Yes No (Please note that if you are currently pregnant, you will be asked to have the Par-X medical form filled out by your doctor or midwife before participation in this program.)

Payment information: **Please note that for security reasons, we do not advise dropping payments off with other merchants in our building.

Payment Amount :
Class fees: April 20 session $120
**Music class families save $24, making your total $96

Yes, I would like to order a water-resistant mat for the Stroll N' Strenthen outdoor class, at a cost of $21.40 (includes pst)

Totals:
12 week fitness only: $120 (if mat added, total = $141.40)
Music class clients total: $96 (if mat added, total = 117.40)

Please list any coupons, discounts or gift certificates you may have: (quote the coupon #)

I will be paying $ by:

In full by cheque- same as cash below or:
Send cheques to our mailing address at: Jump Start Music & Movement #74-1240 Falcon Drive, Coquitlam BC V3E-2B4 **

In full by cash- please drop cash off inside the Jump Start Coquitlam Studio waiting room, in our internal, locked mail box. Envelopes are provided there. Our office hours are 15 minutes before and after each class. See schedule for details.

In full by credit card - (After submitting this form, you will receive a confirmation email with a link to our secure payment page.)

Policies:

• There are no make up classes available for 4 week programs
• Full refunds will be issued if cancellation occurs 14 days or more before the start of the class.
• Cancellations which occur with less than 2 weeks till the start date are subject to a $15 administration fee, with the remainder refunded.
• If the class is cancelled by Jump Start for any reason, a full refund will be issued.
• Occasionally, photos are taken in class and may be used for promotional purposes without remuneration, unless Jump Start has been notified in writing.
• Jump Start is not responsible for loss or injuries incurred while participating in the the Jump Start program. All health concerns must be reported at the time of registration.

I the undersigned have read and understood the attached policies and agree to the terms within. I wish to register myself / my child for the class indicated. I understand that photographs taken in class may be used without financial compensation, unless ohterwise indicated by me in writing. Checking this box indicates my agreement that I will not hold Jump Start Music & Movement responsible for any loss, damages or injury incurred directly or indirectly from participation in the Jump Start Program. If paying by credit card, checking this box also constitutes authorization to charge said card.