Stew Smith's
Heroes of Tomorrow Fitness Center


About Heroes of Tomorrow
 PDF Version of Questionnaire

Fitness Level Questionnaire and Goals / Waiver of Liability                          

Last Name –_______________________  First Name____________________ Age_____ Sex - M / F

City -______________ St______  Phone (H) - _____________ (Cell) -_________________

Email Address _____________________                                                                                

 Current Physical Condition and Goals     










Situps * 






1 mile run



1.5mile run



2 mile run



3 mile run



300m or 400m run



500yd swim



(*maximum or in 1 to 2 minutes max time)

Other Goals - _______________________________________________________________________


Join the military, fire / police department, government agency - By what date___________

If YES - Which branch of service or agency- __________________________________________________


1.  Have you had or do you have any disorders mentioned below? (Y/N)

____Heart Disease    ____Chest Pains                      IF YES - PLEASE ELABORATE:
____Heart Problems ___Back Trouble                     ____________________________
____Anemia            __  Asthma                               ___________________________
____Diabetes           __  Hernia                                 __________________________

___Joint Pain         ___Epilepsy                              
____Fainting Spells  ___High Blood Pressure        

2.  Any history of hospitalizations, operations and/or serious injuries?_______________________________

3.  Are you currently taking any medications?  Please provide specifics._____________________________

By signing I am verifying that the above information is accurate and agree to waive any liability, claims, actions or damage of any kind resulting in the participation in the free pre-military training program taught by my trainer, __________________ , and Stew Smith or the Heroes of Tomorrow Organization.

 I, _____________________________ assume any risks in this program.  

                        signature (if minor - must be signed by parent)