{"id":183,"date":"2014-02-26T17:42:21","date_gmt":"2014-02-27T01:42:21","guid":{"rendered":"http:\/\/progressiveelitetraining.com\/?page_id=183"},"modified":"2019-06-08T14:58:30","modified_gmt":"2019-06-08T21:58:30","slug":"fitness-fore-golf-registration","status":"publish","type":"page","link":"https:\/\/progressiveelitetraining.com\/?page_id=183","title":{"rendered":"Fitness Fore Golf Registration"},"content":{"rendered":"<style type=\"text\/css\">\n.fontStyle_header {\n\tfont-family: Arial, Helvetica, sans-serif;\n\tfont-size: 22px;\n\tline-height: 30px;\n\tfont-weight: bold;\n\tfont-style: italic;\n\tcolor:#4370b9;\n}\n.fontStyle_subheader {\n\tfont-family: Arial, Helvetica, sans-serif;\n\tfont-size:16px;\t\n}\n.fontStyle_standard {\n\tfont-family: Arial, Helvetica, sans-serif;\n\tfont-size: 15px;\n\ttext-align: left;\n}\n.fontLarger {\n\tfont-family: Arial, Helvetica, sans-serif;\n\tfont-size: larger;\n\tfont-weight: bold;\n}\n.nextButton {\n    background: url(.\/images\/next-button.png) no-repeat right top;\n\tmargin-top: -20px;\n    height:29px;\n    width:44px;\n    float:right;\n}\n.nextButton:hover {\n    background-position:right bottom;\n}\n.infoButton {\n    background: url(.\/images\/info-button.png) no-repeat right top;\n\tmargin-top: -20px;\n    height:30px;\n    width:31px;\n    float:right;\n}\n.infoButton:hover {\n    background-position:right bottom;\n}\n.registerButton {\n    background: url(.\/images\/register-button.png) no-repeat right top;\n    font-family:arial,helvetica,sans-serif; \n    font-size: 20px;\n    line-height: 60px;\n\tpadding-top: 0px;\n    height:70px;\n    width:560px;\n    float:right;\n}\n.registerButton:hover {\n    background-position:right bottom;\n}\n.tableWidthLimiter {\n\tmax-width:800px;\n} \n.mainTable {\n\tmargin-left: auto;\n    margin-right: auto;\t\n\tmax-width:800px;\n\tborder:none;\t\n}\ntd { \n    padding: 10px;\n}\nol { \n    padding-left: 30px;\n}\nul { \n    padding-left: 30px;\n}\n.image-left_text-middle > * {\n\tmargin: 0px 15px 0px 0px;\n  \tvertical-align: middle;\n\tfloat: left;<\/p>\n<p>}\n.clearfix_0 {\n    clear:both;\n    height:0px;\n    font-size:0px;\n    line-height:0px;\n}\n.clearfix_05 {\n    clear:both;\n    height:5px;\n    font-size:5px;\n    line-height:5px;\n}\n.clearfix_15 {\n    clear:both;\n    height:15px;\n    font-size:15px;\n    line-height:15px;\n}\n<\/style>\n<div style=\"position:relative; width:100%; max-width:800px; margin-left:auto; margin-right:auto\">\n<table class=\"mainTable\">\n<tr>\n<td align=\"left\" valign=\"middle\" bgcolor=\"#f2f2f2\"><span style=\"color: #000066;\"><b>Register online for Fitness Fore Golf<br \/>\n<\/b><\/span><a href=\".\/?page_id=162\" class=\"infoButton\" title=\"more information about the training program\"><\/a><\/td>\n<\/tr>\n<tr>\n<td height=\"294\" align=\"left\" valign=\"top\" bgcolor=\"#f9f9f9\">\n<table width=\"100%\" border=\"0\" cellspacing=\"0\" cellpadding=\"10\">\n<tr>\n<td height=\"274\" align=\"left\" valign=\"top\">\n\n<!-- Fast Secure Contact Form plugin 4.0.53 - begin - FastSecureContactForm.com -->\r\n<div style=\"clear:both;\"><\/div>\n\r\n<div id=\"FSContact4\" style=\"width:99%; max-width:555px;\">\r\n<form action=\"https:\/\/progressiveelitetraining.com\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F183\" id=\"fscf_form4\" method=\"post\">\r\n\n<div id=\"fscf_div_clear4_0\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_0\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\r\n\t<div style=\"text-align:left; padding-top:5px;\">\n      <label style=\"text-align:left;\" for=\"fscf_name4\">Name:<\/label>\n    <\/div>\r\n\t<div style=\"text-align:left;\">\r\n\t  <input style=\"text-align:left; margin:0; width:99%; max-width:250px;\" type=\"text\" id=\"fscf_name4\" name=\"full_name\" value=\"\"  \/>\r\n\t<\/div>\r\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_1\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_1\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div style=\"text-align:left; padding-top:5px;\">\n      <label style=\"text-align:left;\" for=\"fscf_email4\">Email:<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <input style=\"text-align:left; margin:0; width:99%; max-width:250px;\" type=\"text\" id=\"fscf_email4\" name=\"email\" value=\"\"  \/>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_4\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_4\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_4\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_4\">Address<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <input style=\"text-align:left; margin:0; width:99%; max-width:250px;\" type=\"text\" id=\"fscf_field4_4\" name=\"address\" value=\"\"  \/>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_5\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_5\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_5\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_5\">City<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <input style=\"text-align:left; margin:0; width:99%; max-width:250px;\" type=\"text\" id=\"fscf_field4_5\" name=\"city\" value=\"\"  \/>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_6\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_6\" style=\"clear:left; float:left; width:99%; max-width:250px; margin-right:10px;\">\n    <div  id=\"fscf_label4_6\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_6\">Province\/State<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <input style=\"text-align:left; margin:0; width:300px;FONT-FAMILY: Verdana,Helvetica; FONT-SIZE: 10px;\" type=\"text\" id=\"fscf_field4_6\" name=\"state\" value=\"\"  \/>\n    <\/div>\n  <\/div>\n  <div id=\"fscf_div_follow4_7\" style=\"float:left; padding-left:10px; width:99%; max-width:250px;\">\n\n    <div style=\"clear:both;\"><\/div>\n<div style=\" margin-left:40px;  margin-top:2px;\">ZIP&nbsp;<\/div>\n\n    <div  id=\"fscf_label4_7\" style=\"text-align:left; padding-top:5px;\">\n    <\/div>\n    <div style=\"text-align:left;\">\n      <input style=\"text-align:left; margin-left:40px; width:80px;FONT-FAMILY: Verdana,Helvetica; FONT-SIZE: 10px;\" type=\"text\" id=\"fscf_field4_7\" name=\"zip\" value=\"\"  \/>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_9\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_9\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_9\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_9\">Country<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <input style=\"text-align:left; margin:0; width:99%; max-width:250px;\" type=\"text\" id=\"fscf_field4_9\" name=\"country\" value=\"\"  \/>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_8\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_8\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_8\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_8\">Profession<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <input style=\"text-align:left; margin:0; width:99%; max-width:250px;\" type=\"text\" id=\"fscf_field4_8\" name=\"profession\" value=\"\"  \/>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_10\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_10\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_10\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_10\">Date of Birth<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <input style=\"text-align:left; width:100px;FONT-FAMILY: Verdana,Helvetica; FONT-SIZE: 10px;\" type=\"text\" id=\"fscf_field4_10\" name=\"date-of-birth\" value=\"mm\/dd\/yyyy\"  size=\"15\"  \/>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_11\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_11\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_11\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_11\">Home Phone<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <input style=\"text-align:left; width:100px;FONT-FAMILY: Verdana,Helvetica; FONT-SIZE: 10px;\" type=\"text\" id=\"fscf_field4_11\" name=\"phone-number\" value=\"\"  \/>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_12\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_12\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_12\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_12\">Work Phone<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <input style=\"text-align:left; width:100px;FONT-FAMILY: Verdana,Helvetica; FONT-SIZE: 10px;\" type=\"text\" id=\"fscf_field4_12\" name=\"work-phone\" value=\"\"  \/>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_13\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_13\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_13\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_13\">Cell Phone<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <input style=\"text-align:left; width:100px;FONT-FAMILY: Verdana,Helvetica; FONT-SIZE: 10px;\" type=\"text\" id=\"fscf_field4_13\" name=\"cell-phone\" value=\"\"  \/>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_14\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_14\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_14\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_14\">I rate my current fitness level as a (1-10), ten being high<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <select style=\"text-align:left;\" id=\"fscf_field4_14\" name=\"i-rate-my-current-fitness-level-as-a-1-1[]\">\n        <option value=\"\">Please select<\/option>\n        <option value=\"1\">1 low<\/option>\n        <option value=\"2\">2<\/option>\n        <option value=\"3\">3<\/option>\n        <option value=\"4\">4<\/option>\n        <option value=\"5\">5<\/option>\n        <option value=\"6\">6<\/option>\n        <option value=\"7\">7<\/option>\n        <option value=\"8\">8<\/option>\n        <option value=\"9\">9<\/option>\n        <option value=\"10\"> 10 high<\/option>\n      <\/select>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_16\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_16\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_16\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_16\">How did you hear about us?<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <input style=\"text-align:left; margin:0; width:99%; max-width:250px;\" type=\"text\" id=\"fscf_field4_16\" name=\"how-did-you-hear-about-us\" value=\"\"  \/>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_17\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_17\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_17\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_17\">Please specify publication \/ website \/ friend or other referral<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <input style=\"text-align:left; margin:0; width:99%; max-width:250px;\" type=\"text\" id=\"fscf_field4_17\" name=\"please-specify-publication-website-frien\" value=\"\"  \/>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_18\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_18\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_18\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_18\">This is my first training<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <span><input type=\"radio\" style=\"width:22px; height:32px;\" id=\"fscf_field4_18_1\" name=\"this-is-my-first-training\" value=\"1\" \/> <label style=\"display:inline;\" for=\"fscf_field4_18_1\">yes<\/label><\/span>\n      <span><input type=\"radio\" style=\"width:22px; height:32px;\" id=\"fscf_field4_18_2\" name=\"this-is-my-first-training\" value=\"2\" \/> <label style=\"display:inline;\" for=\"fscf_field4_18_2\">no<\/label><\/span>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_79\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_79\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_79\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_79\">How often do you golf?<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <input style=\"text-align:left; margin:0; width:99%; max-width:250px;\" type=\"text\" id=\"fscf_field4_79\" name=\"how-often-do-you-golf\" value=\"\"  \/>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_19\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_19\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_19\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_19\">What are your goals for your golf game?<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <textarea style=\"text-align:left; margin:0; width:99%; max-width:250px; height:120px;\" id=\"fscf_field4_19\" name=\"my-main-goals-are\" cols=\"30\" rows=\"10\" ><\/textarea>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_81\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_81\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_81\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_81\">Do you experience any pain during your game of golf?<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <span><input type=\"radio\" style=\"width:22px; height:32px;\" id=\"fscf_field4_81_1\" name=\"do-you-experience-any-pain-during-your-g\" value=\"1\" \/> <label style=\"display:inline;\" for=\"fscf_field4_81_1\">yes<\/label><\/span>\n      <span><input type=\"radio\" style=\"width:22px; height:32px;\" id=\"fscf_field4_81_2\" name=\"do-you-experience-any-pain-during-your-g\" value=\"2\" \/> <label style=\"display:inline;\" for=\"fscf_field4_81_2\">no<\/label><\/span>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_82\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_82\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_82\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_82\">Do you presently have any golf injuries?<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <span><input type=\"radio\" style=\"width:22px; height:32px;\" id=\"fscf_field4_82_1\" name=\"do-you-have-any-known-injuries-from-play\" value=\"1\" \/> <label style=\"display:inline;\" for=\"fscf_field4_82_1\">yes<\/label><\/span>\n      <span><input type=\"radio\" style=\"width:22px; height:32px;\" id=\"fscf_field4_82_2\" name=\"do-you-have-any-known-injuries-from-play\" value=\"2\" \/> <label style=\"display:inline;\" for=\"fscf_field4_82_2\">no<\/label><\/span>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_84\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_84\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_84\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_84\">If you answer yes please list.<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <textarea style=\"text-align:left; margin:0; width:99%; max-width:250px; height:120px;\" id=\"fscf_field4_84\" name=\"if-you-answer-yes-please-list\" cols=\"30\" rows=\"10\" ><\/textarea>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_83\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_83\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_83\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_83\">Do you have your doctors permission to take part in this program?<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <span><input type=\"radio\" style=\"width:22px; height:32px;\" id=\"fscf_field4_83_1\" name=\"do-you-have-your-doctors-permission-to-t\" value=\"1\" \/> <label style=\"display:inline;\" for=\"fscf_field4_83_1\">yes<\/label><\/span>\n      <span><input type=\"radio\" style=\"width:22px; height:32px;\" id=\"fscf_field4_83_2\" name=\"do-you-have-your-doctors-permission-to-t\" value=\"2\" \/> <label style=\"display:inline;\" for=\"fscf_field4_83_2\">no<\/label><\/span>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_20\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_20\" style=\"clear:left; float:left; width:99%; max-width:250px; margin-right:10px;\">\n    <div  id=\"fscf_label4_20\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_20\">Name of Emergency Contact<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <input style=\"text-align:left; margin:0; width:300px;FONT-FAMILY: Verdana,Helvetica; FONT-SIZE: 10px;\" type=\"text\" id=\"fscf_field4_20\" name=\"name-of-emergency-contact\" value=\"\"  \/>\n    <\/div>\n  <\/div>\n  <div id=\"fscf_div_follow4_21\" style=\"float:left; padding-left:10px; width:99%; max-width:250px;\">\n\n    <div style=\"clear:both;\"><\/div>\n<div style=\" margin-left:40px;  margin-top:2px;\">& Phone Number<\/div>\n\n    <div  id=\"fscf_label4_21\" style=\"text-align:left; padding-top:5px;\">\n    <\/div>\n    <div style=\"text-align:left;\">\n      <input style=\"text-align:left; margin-left:40px; width:80px;FONT-FAMILY: Verdana,Helvetica; FONT-SIZE: 10px;\" type=\"text\" id=\"fscf_field4_21\" name=\"emergency-phone-number\" value=\"\"  \/>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_23\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_23\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_23\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_23\">Choose your Package\/Price<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <select style=\"text-align:left;\" id=\"fscf_field4_23\" name=\"choose-your-package-price[]\">\n        <option value=\"\">Please select<\/option>\n        <option value=\"1\">2 hours - 6 wks - $99.75 - per week<\/option>\n        <option value=\"2\">2 hours - 8 wks - $94.50 - per week<\/option>\n        <option value=\"3\">3 hours - 6 wks - $144.90 - per week<\/option>\n        <option value=\"4\">3 hours - 8 wks - $132.30 - per week<\/option>\n      <\/select>\n    <\/div>\n\n    <div style=\"clear:both;\"><\/div>\n<p><span style=\"font-size:smaller;\">all prices include GST<\/span><\/p>\r\n<p>Note: <strong>The initial consultation costs are $26.25<\/strong> <span style=\"font-size:smaller;\">(tax included)<\/span>, they will be added to the package price.<\/p>\n\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_24\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_24\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_24\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_24\">Form of payment<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <select style=\"text-align:left;\" id=\"fscf_field4_24\" name=\"form-of-payment[]\">\n        <option value=\"\">Please select<\/option>\n        <option value=\"1\">Cheque<\/option>\n        <option value=\"2\">Cash<\/option>\n      <\/select>\n    <\/div>\n\n    <div style=\"clear:both;\"><\/div>\n<p>&nbsp;<\/p>\n\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_25\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_25\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_25\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_25\">1. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)?<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <span><input type=\"radio\" style=\"width:22px; height:32px;\" id=\"fscf_field4_25_1\" name=\"1-are-you-allergic-to-any-medication-asp\" value=\"1\" \/> <label style=\"display:inline;\" for=\"fscf_field4_25_1\">yes<\/label><\/span>\n      <span><input type=\"radio\" style=\"width:22px; height:32px;\" id=\"fscf_field4_25_2\" name=\"1-are-you-allergic-to-any-medication-asp\" value=\"2\" \/> <label style=\"display:inline;\" for=\"fscf_field4_25_2\">no<\/label><\/span>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_26\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_26\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_26\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_26\">List medications you are allergic to:<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <input style=\"text-align:left; margin:0; width:99%; max-width:250px;\" type=\"text\" id=\"fscf_field4_26\" name=\"list-medications-you-are-allergic-to\" value=\"\"  \/>\n    <\/div>\n\n    <div style=\"clear:both;\"><\/div>\n<hr>\n\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_27\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_27\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_27\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_27\">2. Do you take any prescribed medication on a permanent or semi-permanent basis?<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <span><input type=\"radio\" style=\"width:22px; height:32px;\" id=\"fscf_field4_27_1\" name=\"2-do-you-take-any-prescribed-medication\" value=\"1\" \/> <label style=\"display:inline;\" for=\"fscf_field4_27_1\">yes<\/label><\/span>\n      <span><input type=\"radio\" style=\"width:22px; height:32px;\" id=\"fscf_field4_27_2\" name=\"2-do-you-take-any-prescribed-medication\" value=\"2\" \/> <label style=\"display:inline;\" for=\"fscf_field4_27_2\">no<\/label><\/span>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_28\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_28\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_28\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_28\">List prescribed medications:<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <input style=\"text-align:left; margin:0; width:99%; max-width:250px;\" type=\"text\" id=\"fscf_field4_28\" name=\"list-precribed-medications\" value=\"\"  \/>\n    <\/div>\n\n    <div style=\"clear:both;\"><\/div>\n<hr>\n\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_29\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_29\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_29\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_29\">3. Do you have a seizure disorder (epilepsy)?<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <span><input type=\"radio\" style=\"width:22px; height:32px;\" id=\"fscf_field4_29_1\" name=\"3-do-you-have-a-seizure-disorder-epileps\" value=\"1\" \/> <label style=\"display:inline;\" for=\"fscf_field4_29_1\">yes<\/label><\/span>\n      <span><input type=\"radio\" style=\"width:22px; height:32px;\" id=\"fscf_field4_29_2\" name=\"3-do-you-have-a-seizure-disorder-epileps\" value=\"2\" \/> <label style=\"display:inline;\" for=\"fscf_field4_29_2\">no<\/label><\/span>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_30\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_30\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_30\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_30\">List epilepsy medications:<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <input style=\"text-align:left; margin:0; width:99%; max-width:250px;\" type=\"text\" id=\"fscf_field4_30\" name=\"list-epilepsy-medications\" value=\"\"  \/>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_31\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_31\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_31\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_31\">4. Do you have diabetes Adult or Juvenile?<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <span><input type=\"radio\" style=\"width:22px; height:32px;\" id=\"fscf_field4_31_1\" name=\"4-do-you-have-diabetes-adult-or-juvenile\" value=\"1\" \/> <label style=\"display:inline;\" for=\"fscf_field4_31_1\">yes<\/label><\/span>\n      <span><input type=\"radio\" style=\"width:22px; height:32px;\" id=\"fscf_field4_31_2\" name=\"4-do-you-have-diabetes-adult-or-juvenile\" value=\"2\" \/> <label style=\"display:inline;\" for=\"fscf_field4_31_2\">no<\/label><\/span>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_32\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_32\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_32\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_32\">5. Have you ever been found to be anemic (low blood count)?<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <span><input type=\"radio\" style=\"width:22px; height:32px;\" id=\"fscf_field4_32_1\" name=\"5-have-you-ever-been-found-to-be-anemic\" value=\"1\" \/> <label style=\"display:inline;\" for=\"fscf_field4_32_1\">yes<\/label><\/span>\n      <span><input type=\"radio\" style=\"width:22px; height:32px;\" id=\"fscf_field4_32_2\" name=\"5-have-you-ever-been-found-to-be-anemic\" value=\"2\" \/> <label style=\"display:inline;\" for=\"fscf_field4_32_2\">no<\/label><\/span>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_33\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_33\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_33\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_33\">6. Do you have high blood pressure (hypertension)?<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <span><input type=\"radio\" style=\"width:22px; height:32px;\" id=\"fscf_field4_33_1\" name=\"6-do-you-have-high-blood-pressure-hypert\" value=\"1\" \/> <label style=\"display:inline;\" for=\"fscf_field4_33_1\">yes<\/label><\/span>\n      <span><input type=\"radio\" style=\"width:22px; height:32px;\" id=\"fscf_field4_33_2\" name=\"6-do-you-have-high-blood-pressure-hypert\" value=\"2\" \/> <label style=\"display:inline;\" for=\"fscf_field4_33_2\">no<\/label><\/span>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_34\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_34\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_34\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_34\">List high blood pressure medications:<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <input style=\"text-align:left; margin:0; width:99%; max-width:250px;\" type=\"text\" id=\"fscf_field4_34\" name=\"list-high-blood-pressure-medications\" value=\"\"  \/>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_35\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_35\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n\n    <div style=\"clear:both;\"><\/div>\n<p>7. Do you have or have you ever had the following diseases?\n\n    <div  id=\"fscf_label4_35\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_35\">Heart disease<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <span><input type=\"radio\" style=\"width:22px; height:32px;\" id=\"fscf_field4_35_1\" name=\"heart-disease\" value=\"1\" \/> <label style=\"display:inline;\" for=\"fscf_field4_35_1\">yes<\/label><\/span>\n      <span><input type=\"radio\" style=\"width:22px; height:32px;\" id=\"fscf_field4_35_2\" name=\"heart-disease\" value=\"2\" \/> <label style=\"display:inline;\" for=\"fscf_field4_35_2\">no<\/label><\/span>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_36\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_36\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_36\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_36\">Lung disease<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <span><input type=\"radio\" style=\"width:22px; height:32px;\" id=\"fscf_field4_36_1\" name=\"lung-disease\" value=\"1\" \/> <label style=\"display:inline;\" for=\"fscf_field4_36_1\">yes<\/label><\/span>\n      <span><input type=\"radio\" style=\"width:22px; height:32px;\" id=\"fscf_field4_36_2\" name=\"lung-disease\" value=\"2\" \/> <label style=\"display:inline;\" for=\"fscf_field4_36_2\">no<\/label><\/span>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_37\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_37\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_37\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_37\">Kidney disease<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <span><input type=\"radio\" style=\"width:22px; height:32px;\" id=\"fscf_field4_37_1\" name=\"kidney-disease\" value=\"1\" \/> <label style=\"display:inline;\" for=\"fscf_field4_37_1\">yes<\/label><\/span>\n      <span><input type=\"radio\" style=\"width:22px; height:32px;\" id=\"fscf_field4_37_2\" name=\"kidney-disease\" value=\"2\" \/> <label style=\"display:inline;\" for=\"fscf_field4_37_2\">no<\/label><\/span>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_38\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_38\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_38\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_38\">Liver disease<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <span><input type=\"radio\" style=\"width:22px; height:32px;\" id=\"fscf_field4_38_1\" name=\"liver-disease\" value=\"1\" \/> <label style=\"display:inline;\" for=\"fscf_field4_38_1\">yes<\/label><\/span>\n      <span><input type=\"radio\" style=\"width:22px; height:32px;\" id=\"fscf_field4_38_2\" name=\"liver-disease\" value=\"2\" \/> <label style=\"display:inline;\" for=\"fscf_field4_38_2\">no<\/label><\/span>\n    <\/div>\n\n    <div style=\"clear:both;\"><\/div>\n<\/p>\n\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_39\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_39\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_39\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_39\">8. Do you have asthma?<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <span><input type=\"radio\" style=\"width:22px; height:32px;\" id=\"fscf_field4_39_1\" name=\"8-do-you-have-asthma\" value=\"1\" \/> <label style=\"display:inline;\" for=\"fscf_field4_39_1\">yes<\/label><\/span>\n      <span><input type=\"radio\" style=\"width:22px; height:32px;\" id=\"fscf_field4_39_2\" name=\"8-do-you-have-asthma\" value=\"2\" \/> <label style=\"display:inline;\" for=\"fscf_field4_39_2\">no<\/label><\/span>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_40\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_40\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_40\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_40\">List asthma medications:<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <input style=\"text-align:left; margin:0; width:99%; max-width:250px;\" type=\"text\" id=\"fscf_field4_40\" name=\"list-asthma-medications\" value=\"\"  \/>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_41\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_41\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_41\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_41\">9. Have you ever had a neck injury? (if yes, describe)<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <textarea style=\"text-align:left; margin:0; width:99%; max-width:250px; height:120px;\" id=\"fscf_field4_41\" name=\"9-have-you-ever-had-a-neck-injury\" cols=\"30\" rows=\"10\" ><\/textarea>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_42\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_42\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n\n    <div style=\"clear:both;\"><\/div>\n<strong>10. Have you ever had a shoulder injury?<\/strong> <br>If yes, is there any residual pain and are you receiving therapy?\n\n    <div  id=\"fscf_label4_42\" style=\"text-align:left; padding-top:5px;\">\n    <\/div>\n    <div style=\"text-align:left;\">\n      <textarea style=\"text-align:left; margin:0; width:99%; max-width:250px; height:120px;\" id=\"fscf_field4_42\" name=\"10-have-you-ever-had-a-shoulder-injury-i\" cols=\"30\" rows=\"10\" ><\/textarea>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_43\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_43\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_43\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_43\">11. Have you ever been knocked out?<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <textarea style=\"text-align:left; margin:0; width:99%; max-width:250px; height:120px;\" id=\"fscf_field4_43\" name=\"11-have-you-ever-been-knocked-out\" cols=\"30\" rows=\"10\" ><\/textarea>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_44\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_44\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_44\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_44\">12. Do you wear glasses or contact lenses?<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <span><input type=\"radio\" style=\"width:22px; height:32px;\" id=\"fscf_field4_44_1\" name=\"12-do-you-wear-glasses-or-contact-lenses\" value=\"1\" \/> <label style=\"display:inline;\" for=\"fscf_field4_44_1\">yes<\/label><\/span>\n      <span><input type=\"radio\" style=\"width:22px; height:32px;\" id=\"fscf_field4_44_2\" name=\"12-do-you-wear-glasses-or-contact-lenses\" value=\"2\" \/> <label style=\"display:inline;\" for=\"fscf_field4_44_2\">no<\/label><\/span>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_45\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_45\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_45\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_45\">13. Have you had a broken bone or fracture in the past 2 years?<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <textarea style=\"text-align:left; margin:0; width:99%; max-width:250px; height:120px;\" id=\"fscf_field4_45\" name=\"13-have-you-had-a-broken-bone-or-fractur\" cols=\"30\" rows=\"10\" ><\/textarea>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_46\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_46\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_46\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_46\">14. Have you ever injured your back?<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <textarea style=\"text-align:left; margin:0; width:99%; max-width:250px; height:120px;\" id=\"fscf_field4_46\" name=\"14-have-you-ever-injured-your-back\" cols=\"30\" rows=\"10\" ><\/textarea>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_47\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_47\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_47\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_47\">15. Do you have back pain?<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <select style=\"text-align:left;\" id=\"fscf_field4_47\" name=\"15-do-you-have-back-pain[]\">\n        <option value=\"\">Please select<\/option>\n        <option value=\"1\">never<\/option>\n        <option value=\"2\">seldom<\/option>\n        <option value=\"3\">occasionally<\/option>\n        <option value=\"4\">frequently<\/option>\n      <\/select>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_48\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_48\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_48\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_48\">16. Have you had knee pain in the past 6 months that has disabled you for longer than a week?<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <textarea style=\"text-align:left; margin:0; width:99%; max-width:250px; height:120px;\" id=\"fscf_field4_48\" name=\"16-have-you-had-knee-pain-in-the-past-6\" cols=\"30\" rows=\"10\" ><\/textarea>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_49\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_49\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_49\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_49\">17. Do you have other physical conditions which cause pain?<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <textarea style=\"text-align:left; margin:0; width:99%; max-width:250px; height:120px;\" id=\"fscf_field4_49\" name=\"17-do-you-have-other-physical-conditions\" cols=\"30\" rows=\"10\" ><\/textarea>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_50\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_50\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_50\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_50\">18. Detail any surgical procedures in the past 6 months:<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <textarea style=\"text-align:left; margin:0; width:99%; max-width:250px; height:120px;\" id=\"fscf_field4_50\" name=\"18-detail-any-surgical-procedures-in-the\" cols=\"30\" rows=\"10\" ><\/textarea>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_52\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_52\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_52\" style=\"text-align:left; padding-top:5px;\">\r\n\t  <label style=\"text-align:left;\" for=\"fscf_field4_52\">19. Are you training for a specific event? If yes, explain:<\/label>\n    <\/div>\n    <div style=\"text-align:left;\">\n      <textarea style=\"text-align:left; margin:0; width:99%; max-width:250px; height:120px;\" id=\"fscf_field4_52\" name=\"19-are-you-training-for-a-specific-event\" cols=\"30\" rows=\"10\" ><\/textarea>\n    <\/div>\n\n    <div style=\"clear:both;\"><\/div>\n<hr>\r\n<p>Before starting any fitness\/health\/nutrition program it is wise to seek your doctors advice. <\/p>\r\n<p>RELEASE FORM AND LIABILITY WAIVER. PLEASE READ, CHECK THE BOXES AND SIGN BELOW. <\/p>\r\n<p>This release is entered into between the undersigned and Progressive Elite Training, its officers, subsidiaries affiliates, and executors in addition to the city of Penticton. The purpose of Progressive Elite Training is to provide fitness instruction and coaching for various levels of athletes\/individuals <\/p><hr>\r\n<p><strong>The undersigned hereby acknowledges that the following was explained to me and or agree to the following:<\/strong><\/p>\n\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_53\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_53\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_53\" style=\"text-align:left; padding-top:5px;\">\n    <\/div>\n    <div style=\"text-align:left;\">\n      <span><input type=\"checkbox\" style=\"width:22px; height:32px;\" id=\"fscf_field4_53\" name=\"acknowledges-that-sheila-kamaraus-is-not\" value=\"1\" \/> <label style=\"display:inline;\" for=\"fscf_field4_53\">acknowledges that Sheila Kamaraus is not a physician and is not trained in any way to provide medical diagnosis, medical treatment, or any other type of medical advice.<\/label><\/span>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_54\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_54\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_54\" style=\"text-align:left; padding-top:5px;\">\n    <\/div>\n    <div style=\"text-align:left;\">\n      <span><input type=\"checkbox\" style=\"width:22px; height:32px;\" id=\"fscf_field4_54\" name=\"exerciser-hereby-stipulates-that-heshe-i\" value=\"1\" \/> <label style=\"display:inline;\" for=\"fscf_field4_54\">exerciser hereby stipulates that he\/she is physically sound and that he\/she has approval to proceed with a routine of exercise.<\/label><\/span>\n    <\/div>\n  <\/div>\n<\/div>\n\n<div id=\"fscf_div_clear4_55\" style=\"clear:both;\">\n  <div id=\"fscf_div_field4_55\" style=\"clear:left; float:left; width:99%; max-width:550px; margin-right:10px;\">\n    <div  id=\"fscf_label4_55\" style=\"text-align:left; padding-top:5px;\">\n    <\/div>\n    <div style=\"text-align:left;\">\n      <span><input type=\"checkbox\" style=\"width:22px; height:32px;\" id=\"fscf_field4_55\" name=\"limitations-of-exercise-if-any-it-is-fur\" value=\"1\" \/> <label style=\"display:inline;\" for=\"fscf_field4_55\">LIMITATIONS OF EXERCISE IF ANY: it is further expressly agreed that all strength training, cardiovascular exercise, or any other exercise shall be undertaken by me at my sole risk and that Sheila Kamaraus her agents or employees shall not be liable to me for claims, demands, injuries, damages, actions or causes of action whatsoever, to my person or property arising out of or connected with the use by me of the services provided and of the premises where the same is located . I do hereby expressly forever release and discharge Sheila Kamaraus and her agents or employees from all such claims, demands, injuries, damages, actions or causes of action, from all acts of active or passive negligence on the part of Sheila Kamaraus and her agents or employees.<\/label><\/span>\n    <\/div>\n  <\/div>\n<\/div>\r\n<div style=\"clear:both;\"><\/div>\n\n<div id=\"fscf_submit_div4\" style=\"text-align:left; clear:both; padding-top:15px;\">\r\n\t\t<input type=\"submit\" id=\"fscf_submit4\" style=\"cursor:pointer; margin:0;\" value=\"Submit\" \/> \n<\/div>\n\n<input type=\"hidden\" name=\"fscf_submitted\" value=\"0\" \/>\n<input type=\"hidden\" name=\"fs_postonce_4\" value=\"aaf527c4ccc626abffebaf036d183c0d,1777506782\" \/>\n<input type=\"hidden\" name=\"si_contact_action\" value=\"send\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"4\" \/>\n<input type=\"hidden\" name=\"mailto_id\" value=\"1\" \/>\n\n<\/form>\n<\/div>\r\n<div style=\"clear:both;\"><\/div>\n\n<!-- Fast Secure Contact Form plugin 4.0.53 - end - FastSecureContactForm.com -->\n<\/td>\n<\/tr>\n<\/table>\n<\/td>\n<\/tr>\n<tr>\n<td height=\"80\" align=\"center\" valign=\"middle\" bgcolor=\"#f2f2f2\">\n<div style=\"max-width:520px; text-align:center; margin-left: auto; margin-right: auto; font-family:sans-serif; font-size:38px; color: #000066;\">\n<span style=\"float: left; margin: 0 30px 20px 0;\">Decide.<\/span><span style=\"float: left; margin: 0 30px 20px 0;\">Commit.<\/span><span style=\"float: left; margin: 0 30px 20px 0;\">Succeed.<\/span>\n<\/div>\n<\/td>\n<\/tr>\n<\/table>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Register online for Fitness Fore Golf Decide.Commit.Succeed.<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":9,"menu_order":33,"comment_status":"closed","ping_status":"closed","template":"page-fullwidth.php","meta":[],"_links":{"self":[{"href":"https:\/\/progressiveelitetraining.com\/index.php?rest_route=\/wp\/v2\/pages\/183"}],"collection":[{"href":"https:\/\/progressiveelitetraining.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/progressiveelitetraining.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/progressiveelitetraining.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/progressiveelitetraining.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=183"}],"version-history":[{"count":5,"href":"https:\/\/progressiveelitetraining.com\/index.php?rest_route=\/wp\/v2\/pages\/183\/revisions"}],"predecessor-version":[{"id":588,"href":"https:\/\/progressiveelitetraining.com\/index.php?rest_route=\/wp\/v2\/pages\/183\/revisions\/588"}],"up":[{"embeddable":true,"href":"https:\/\/progressiveelitetraining.com\/index.php?rest_route=\/wp\/v2\/pages\/9"}],"wp:attachment":[{"href":"https:\/\/progressiveelitetraining.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=183"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}