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Member Information
Welcome to Rock Steady Boxing! We are pleased to welcome you into our program. To begin, please complete the following information form

Member Information Form

Please tell us about yourself

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Date *

Name *

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Date of Birth *

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Emergency Contact Information

Name *

Relationship to you *

Best phone # to reach them *

Which symptoms are you experiencing? *

Tremors Postural Changes Loss of Balance Slowness of Movement Depression

Symptoms: Must get medical release

CHECK ALL THAT APPLY TO YOU *

You experience chest discomfort with exertion You experience unreasonable breathlessness You experience dizziness, fainting or blackouts You take heart medications None of the above

What symptoms of Parkinson’s are you experiencing in your daily life?

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What Our Clients Are Saying

"I have Parkinson's Disease, and I feel like the disease has taken away so much from me. Playing the drums in Doug's class is something new that I have added, something I can do now and in the future and I am so happy I joined this class!" - Ada W

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