Learn more about the 60-day challenge at Harbor Square Athletic Club.

Participant Info and Consent.

First Name*

Last Name*

Street Address

City

Email*

Entering your email is for us to notify you of challenge news, tips, events, and other important info that pertains to the challenge. We will NOT spam you or share your email with anyone.

Phone

How did you hear about the HSAC 60-Day Challenge?*

Facebook
Instagram
Email
myEdmondsNews
Current Member
In Club Marketing (newsletter/poster)

What size shirt do you wear?*

S - Small
M- Medium
L -Large
XL - Extra Large
XXL - Extra Extra Large

The shirt will be an Anvil - Unisex Cotton Blend Shirt

Date of Birth*

Challenge terms and consent

By typing your name below, you are agreeing to the stipulations and requirements of Harbor Square Athletic Club and the HSAC 60-Day Challenge. Please read the information carefully, type your name in the blank provided above to indicate you accept the challenge and its terms.

Typing my name above signifies I understand that the HSAC 60-Day Challenge is not a medically supervised system and was developed for healthy people with no medical conditions or risks (physical or psychological) If I have an existing medical condition, before I can begin, I will present my assigned Team Captain with a Physician’s Release Form, signed and date by my personal physician.

I will not hold Harbor Square Athletic Club or any related persons or parties personally liable for any problems, illnesses, or injuries that might occur due to a sudden change in my eating habits.

This weight management program does not replace the expert advice or medical treatment of my own private doctor. I have given my Team Captain, Assistant Captain, Training Staff, all the necessary information about myself to prevent any complications.

All photos and videos taken of my likeness by Harbor Square Athletic Club can be used in conjunction with the HSAC 60-Day Challenge program and other promotion of their weight loss and training programs. I release all claims for any compensation from the use of these photos and understand they will be the property of Harbor Square Athletic Club to be used at their discretion for promotion and marketing campaigns.

Type your name to accept challenge:*

Physical Activity Readiness Questionnaire

Please read each question carefully and answer either “yes” or “no”.

1. Have you been diagnosed with a heart condition?*

2. Do you have chest pain brought on by physical activity?*

3. Do you tend to lose consciousness or fall over as a result of dizziness?*

4. Are you taking medication for your blood pressure or a heart condition?*

5. Do you have a bone or joint problem that could be aggravated by the proposed physical activity?*

If "yes" to #5 - Please explain.

6. Are there other physical ailments we should be aware of and monitor as you engage in this activity?*

If "yes" to #6 - Please explain.

7. Have you undergone any surgery in the past two years (major or minor)?*

If "yes" to #7 - Please explain.

8. Are you over the age of 65 and not accustomed to vigorous exercise?*

9. Is there anything, not mentioned above, that we should be aware of in order to design a safe and effective workout program for you?*

If "yes" to #9 - please describe in detail.

Health History

Please check all that apply.

Heart Disease or Stroke
Lung/Pulmonary Disease
Gastrointestinal Disease
Diabetes
Metabolic Disease
Pregnancy/Trying to Conceive
Anemia

High Blood Pressure
Kidney/Liver Disease
Chronic Diarrhea
Food Allergies
Immune System Disease
Breastfeeding
Hypertension

Cancer
Ulcer
Depression
Neuromuscular Disease
Diagnosed Eating Disorder
Pancreatitis
Hypoglycemia

Health Habits

Please answer the following questions.

Do you smoke?

If "yes" to smoking, how much?

Rarely/Social Settings
Less than one pack per day
More than one pack per day

Do you drink alcohol?

If "yes" to drinking alcohol, how much?

Rarely/Social Settings
One to two beverages per week.
Three to four beverages per week.
Five or more beverages per week.

How much do you sit per day?

Please consider commuting, leisure, and work.

Does your work require travel?

Can you share what type of work you do (optional)?

This question is asked to help determine repetitive movement patterns (sitting, lifting, rotating, etc.) that we can keep in consideration for your fitness plan. Also it helps us work with your schedule in creating a program.

How much sleep do you get per night?

Do you feel rested and rejuvenated when you wake?

Select what best describes you.

How often do you cook your own meals?

What best describes your meals overall?

What supplements, if any, are you taking?

Which supplements would you like more info on?

General health supplements (multi, omega-3, calcium, etc.)
Weight Loss (lean protein powder, fat burner, carb blocker, etc)
Lean Muscle Gain (Protein, Amino Acid, Pre-workout)
Athletic Performance (Creatine, Protein Powder/Bars)
General Info to learn more how supplements can help me overall.

HSAC 60-Day Challenge Goals

Share with us your goals and how we can support you during this challenge.

Which category will you be entering?*

What is you goal weight loss in pounds (lbs)?*

Please keep in mind that 'healthy' weight loss is at a rate of 1 - 3lbs per week. However each person is different and results will vary.

What is your goal in lean muscle gain?*

What motivated you to join the challenge?

Check all that apply.

Please let us know how we can best support you during this challenge, or list any questions that you may have.

Challenge intake form.
Help us. Help you.

Complete the form below.

Participant Info and Consent.

Challenge terms and consent

Physical Activity Readiness Questionnaire

Health History

Health Habits

HSAC 60-Day Challenge Goals

Challenge intake form. Help us. Help you.

Complete the form below.

Participant Info and Consent.

Challenge terms and consent

Physical Activity Readiness Questionnaire

Health History

Health Habits

HSAC 60-Day Challenge Goals

Challenge intake form.
Help us. Help you.