Registration

If you're interested in joining one of Mackie Shilstone's Programs for 2010, please complete the registration form. Space is limited. All applications are accepted. Your application will be evaluated and you will be contacted. All information will be kept confidential.

Click here for a printable application. Return completed application by fax to 504-457-3111.

Note: Fields marked with an asterisk (*) are required.

Personal Information
Program Interest: *
First Name: *
Last Name: *
Address:
City, State, Zip:
Home Phone:
Daytime Phone:
Email Address:
Age:
Sex:
Marital Status:
Health:
Dominant Side:
Height:
Weight:
% Body Fat (if known):
   
Health History
Primary Care Physician:
Physician's Address:
Physician's City, State, Zip:
Physician's Phone Number:
Injury (if any):
Date Injury Occurred:
If injured, where and how did the injury occur?
Physician's Diagnosis of Injury:
Status of Injury (i.e., surgery/rehab):
If surgery, name of surgeon:
Surgeon's Phone Number:
If rehab, name of therapist:
Therapist Phone Number:
Where was rehab performed?
Any other injuries or non-sports related health problems?
   
Tell Us A Little About Yourself
Background (school, hobbies, career objectives)
Your expectations of The Fitness Principle
How did you hear about The Fitness Principle?
EJGH.org    
Mackie Shilstone website Current Client
Advertising Other
   
Medical History (To be completed by applicant)
Applicant's Name:
Address:
City, State, Zip:
Date of Birth:
Home Phone:
Sports:
SSN:
Employer:
Work Phone:
Insurance Company:
Policy #:
Family Physician:

Please answer the following questions by selecting the appropriate response. Use the space below to explain any "Yes" answers to the following questions. Have or do you:

01. Have a medical problem or injury since your evaluation? Yes No
02. Ever not been allowed to participate in sports for a medical reason? Yes No
03. Ever been hospitalized? Yes No
04. Ever had surgery? Yes No
05. Have any missing organs (i.e., kidney, eye, testicle)? Yes No
06. Presently take any medication? Yes No
07. Have any allergies to medicine or insect bites? Yes No
08. Passed out during or after exercise? Yes No
09. Been dizzy during or after exercise? Yes No
10. Have chest pain during or after exercise? Yes No
11. Tire more quickly than your friends during exercise? Yes No
12. Have high blood pressure? Yes No
13. Been told you have a heart murmur? Yes No
14. Have racing of the heart or skipped heartbeats? Yes No
15. Have a family member that died of heart problems or sudden death before age 50? Yes No
16. Have any skin problems? Yes No
17. Ever had a head or neck injury? Yes No
18. Ever been knocked out or unconscious? Yes No
19. Ever had a seizure? Yes No
20. Ever had a stinger, burner, or pinched nerve? Yes No
21. Ever had heat cramps? Yes No
22. Ever been dizzy or passed out in the heat? Yes No
23. Have trouble with breathing or coughing during or after activity? Yes No
24. Use any special equipment (pads, braces, neck rolls, eye guards, kidney belt, etc.)? Yes No
25. Have any problems with vision? Yes No
26. Wear glasses or contacts? Yes No
27. Ever sprained/strained, dislocated, fractured, or had repeated swelling for any bones or joints? Yes No
28. Have any medical problems listed below?
If Yes, please check all that apply:		 Yes No
 
High Blood Pressure Hepatitis Asthma
Rheumatic Fever Abnormal Bleeding Mononucleosis
Diabetes Tuberculosis Other (List)
Please explain all YES answers from the questions above:
 
Health Behavior
01. Do you sometimes feel that if you could only lose weight, you would then be able to achieve most or all of your other goals? Yes No
02. Are you frequently depressed because you feel "fat" or overweight? Yes No
03. Do you frequently overeat (or frequently control the amount you eat) when you are under pressure or when you are unhappy? Yes No
04. Would you eat more than others if you did not control yourself? Yes No
05. Do you feel “good” or “bad” according to how much you eat, how much you weigh, or how much exercise you get? Yes No
06. Does weighing too much (or being “fat”) make you feel lonely? Yes No
07. Do you spend most of the time thinking about how much you have eaten or will be eating during the day? Yes No
08. Are you frightened at the thought of eating situations where you will have to eat a “normal” meal? Yes No
09. Do you frequently eat beyond the point of fullness, to the point of physical discomfort? Yes No
10. When you feel full, do you also feel self-hatred, desperation, panic or depression? Yes No
11. Are there certain foods that you do not feel comfortable eating in front of others? Yes No
12. Do you have a list of foods that you feel are “bad” and/or “good”? Yes No
13. Do you avoid eating for long periods of time as a way to control your weight? Yes No
14. Do you feel compelled to eat when you are home alone? Yes No
15. Do you secretly crave food? Yes No
16. Do your eating and weight loss activities ever interfere with work, school and/or relationships? Yes No
17. Do you feel frightened of food or eating? Yes No
18. Do you get angry at people if they question what or how much you eat? Yes No
19. Do you find you cannot stop thinking about food and weight, or that it intrudes in your thoughts much or most of the time? Yes No
   
You must answer all questions below in order to be considered:
01. The above information is current and correct to the best of my knowledge. Yes No
02. If in the judgment of a representative of the Program, I need care or treatment as a result of an injury or sickness, I do hereby request, consent to and authorize such care as may be deemed necessary. Yes No
03. I recognize the evaluation to be done is a standard pre-participation screening examination, and that no in-depth testing, x-rays, lab work, or cardiac test work will be performed. Yes No
 
Waiver
Review the Waiver of Liability
The Waiver of Liability must be reviewed by the applicant, or by the applicant's legal guardian if applicant is under 18 years of age. You must agree to register for The Fitness Principle with Mackie Shilstone at East Jefferson General Hospital.

PARTICIPATION AGREEMENT

I have voluntarily requested and agreed to participate in The Fitness Principal Program. In consideration for being permitted to participate, I hereby agree and represent that:

  1. I understand that The Fitness Principal, East Jefferson General Hospital, The Wellness Center, and Cecil “Mackie” Shilstone (hereinafter referred to collectively as “The Fitness Principal Program” and includes by reference the employees or agents of each) will take reasonable efforts to assure my safety while participating in the training and exercise Program. I understand however that there are unavoidable risks of physical injury or resulting damage such as heart attack and stroke associated with any exercise and training program, as well as the activities incident thereto, (hereinafter reference to as the "Program" or "participation in the Program"). I understand that these risks of injury and/or damage may also be caused by third parties or circumstances or events over which neither The Fitness Principle nor anyone for whom The Fitness Principle may be responsible or related, has control or could reasonably foresee.

  2. I represent and warrant that I do not know of any medical condition, symptom or any other reason that would prevent me from undertaking the exercise and training Program or increase my risk beyond those inherent in the exercise and training Program. I understand that the training and exercise program will be strenuous and involve a variety of exercise and training activities at various locations.

  3. I understand that The Fitness Principle does not guarantee my safety or that I will remain free from injury and/or damage during participation in the Program.

  4. I acknowledge and agree that my participation in the Program is completely voluntary and made with full knowledge of the inherent risks of injury and/or damage that may occur during participation in the Program.

  5. I understand that, although The Fitness Principle has made reasonable efforts to assure my safety while participating in the Program, that there are unavoidable risks in participation in the Program, and I hereby release and promise not to sue The Fitness Principle or any of their employees or agents for any damages or injury (including death) caused by, arising out of, or related to my participation in the Program, except for such damages or injury as may be caused by the negligence or fault of The Fitness Principle or its employees or agents.

  6. I represent that at all times during my participation in the Program I will be covered by health insurance to provide adequate coverage for any injuries, illnesses or damages that I may sustain or experience. By my signature below I certify that I have confirmed that my health insurance will adequately cover any injuries, illnesses or damages that I may sustain or experience. I hereby release The Fitness Principle, its employees and agents from any responsibility or liability for expenses incurred by me for injuries or illnesses (including death) that I may incur because of those injuries or illnesses.

  7. I agree to defend, indemnify and hold harmless (including attorney's fees and costs) The Fitness Principle from and against any and all losses, claims, demands, liabilities or causes of action of every kind and character for personal injury to or illness of or death of any employee or invitee of The Fitness Principle which injury, illness or death arises out of or is in connection with or is in any way incidental to my acts, fault, omission, negligence or breach of any obligation pursuant to the Program; except I shall not be required to defend, indemnify and hold harmless The Fitness Principle to the extent such injury, illness or death is caused by negligence of The Fitness Principle.

  8. I understand that although The Fitness Principle will attempt to maintain the Program as described to me, it reserves the right to change the Program, including the itinerary, travel arrangements, or accommodations at any time and for any reason, with or without notice, and that The Fitness Principle shall not be responsible or liable for any expenses or losses that I may sustain because of these changes.

  9. I understand that The Fitness Principle reserves the right to decline to accept or continue to retain me in the Program at any time should my actions or general behavior, in the sole discretion of The Fitness Principle be determined to impede, obstruct, or present a risk of harm to me or others affiliated with the Program in any way.

  10. I agree that, should any provision or aspect of this Agreement be found to be unenforceable, that all the remaining provisions of the Agreement will remain in full force and effect.

  11. I represent that my agreement to the provisions herein is wholly voluntary, that the provisions herein are understood by me and are reasonable. I further understand that, prior to signing this Agreement, I have the right to consult with any advisor, counselor, or attorney of my choice.

  12. I agree that, should there be any dispute concerning my participation in the Program that will require the adjudication of a court of law, such adjudication will occur in the courts of and be determined by the laws of the State of Louisiana and venue shall only be proper in the Parish of Jefferson, State of Louisiana.

  13. This Agreement represents my complete understanding with The Fitness Principle concerning its responsibility and liability for my participation in the Program and that it supercedes any previous or contemporaneous understandings I may have had on this subject, whether written or oral, and that this agreement cannot be changed or amended in any way without written concurrence. The language and all parts of this Agreement shall be construed in all cases according to its fair meaning, and no for or against either party to this Agreement. The rule of construction to the effect that any ambiguities against the drafting party shall not be employed in the interpretation of this Agreement.
Yes, I Agree *
 
 
Medical Clearance
01. Do you have a primary care physician? Yes No
  If yes, is your primary care physician at East Jefferson General Hospital? Yes No
  Name of Provider:
02. Have you had a physical from a health care provider within the past 12 months? Yes No
03. Have you had blood work from a heath care provider within the past 12 months? Yes No
04.

Would you like East Jefferson General Hospital to provide your medical clearance to enter into The Fitness Principle with Mackie Shilstone at East Jefferson General Hospital?

 Yes No
  If no, please supply the name of the name of the provider that will provide medical clearance:
  Name of Provider:
 
I understand that there may be diagnostic tests performed that may not be covered by insurance and that I will be responsible for those tests. I understand that if I have had a physical by my health care provider and opt for Joseph Tamimie, M.D., Medical Director for The Fitness Principle with Mackie Shilstone at East Jefferson General Hospital, to provide medical clearance at this time, I will be personally responsible for any services not covered by my insurance.
Yes, I Agree *
   
Physician Checklist
Click here to download and print the Physician Checklist.
   
Medical Release Form
Click here to download and print the Medical Release Form. Return completed form by fax to The Fitness Principle at 504-457-3111.