Mayor’s Council Physical Fitness Challenge

Parks & Recreation
Creating Community through People, Parks and Programs

Mayor’s Council Physical Fitness Challenge

To register for the Mayor's Physical Fitness Challenge complete and submit the form below.

* = Required Field

Participant

Name:	*
Address:	*
City:	, MO.*
Zip:	*
Email:	*
Phone:	*
Sex:
Age:
Race/ethnicity:
Height:	inches
Weight:	lbs

Physical Fitness Questionare

1. Are you currently physically active? (If the answer is no, skip to question 6)

Yes No

2. If yes, how many days per week?

3. On average, how many minutes per session?

4. What intensity (subjective assessment)?

light moderate vigorous

5. Please list your three main forms of exercise: i.e. walking, running, golfing, gardening, swimming, etc.

1.
2.
3.

6. If you are currently not physically active, what are the three main reasons for you not being active?

1.
2.
3.

7. What are/will be your three main goals from a regular exercise program?

1.
2.
3.

Before starting a vigorous physical activity/fitness program, if you are a male over 40 years of age or female over 50 years of age, and have cardiovascular disease (CVD or heart attack, stroke, bypass surgery, angioplasty/stent, etc.) or have one or more risk factors for cardiovascular disease (use tobacco products, high blood pressure, sedentary, high cholesterol, diabetes, overweight, low HDL, family history) or if you are having symptoms of CVD (pressure, tightness, squeezing chest pain which may radiate to arm, neck, or jaw, shortness of breath, unusual weakness, fatigue, etc), or if you have any orthopedic such as arthritis or osteoporosis or other condition which may warrant specific exercise advice, the Mayor’s Council strongly encourages you to consult your physician for medical clearance and advice.

Please verify your information before selecting submit.

Thank you for completing the registration form.