New Starter form

Please use this form to provide us with your contact Information.

Full Name*

Date of Birth*

Telephone Number*

Email Address*

ICE Name :*

Please provide the NAME and relationship of who we can contact in the event of an emergency.

ICE Number:*

Please provide the mobile or landline of the person you would like us to contact in an emergency

Class?

Please tell us which classes you are interested in attending:

Select or enter value

How did you hear about us?

Select or enter value

PARQ

Please use this form to provide full information and details of any medical/health issues. Regular exercise is associated with many health benefits yet any change in your activity level may increase the risk of injury. please answer the following questions honestly and if you are in any doubt as to whether you should undertake our training please consult your doctor before commencing training.

Question 1:*

Do you suffer from any heart or respiratory problems? (if so please use the space below to detail and include any medications)

Yes

Question 2*

Do you suffer from Chest pain or dizzyness?

Yes

Question 3*

Have you ever suffered from high blood pressure?

Yes

Question 4*

Have you ever suffered from bone or joint problems, such as arthritis, that may be aggravated or made worse by exercise? (if yes detail below)

Yes

Question 5*

Have you ever suffered from any kind of back injury?

Yes

Question 6*

Are you or have you been pregnant within the last 6 months?

Yes

Question 7*

Are you taking any medication?

Yes

Question 8*

Are you registered disabled?

Yes

Question 9*

Is there any reason not stated that you feel may result in you being unfit to undertake physical activity?

Yes

Question 10

Please can you expand on any of the above questions or detail any condition not already covered:

Date Signed*

Signature*

Send me a copy of my responses

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