MEMBER REGISTRATION FORM

Lets start with the basics...

   
First Name: Surname:
Address: Your Bithday: dd/mm/yyyy
Postcode: Email:
Phone:    
T-Shirt Style: Green Black White (select one) T-Shirt Size: S M L XL XXL (select one)

On a scale of 1 to 10...

   
How fit and energetic do you feel now?
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How motivated are you to improve your fitness and energy levels?
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How supportive is your partner / family to help you achieve your goals?
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Do you need to see your doctor?

If you answer “yes” to one on the left or to two on the right,
you should visit your health professional before starting an exercise program.

 
Have you had: Are you at risk of cardiovascular disease:
A heart attack Yes   Have a family history of heart disease Yes  
Heart surgery Yes   Are diabetic Yes  
A Pacemaker Yes   Are physically inactive Yes  
Heart Failure Yes   Have epilepsy Yes  
Heart Valve Disease Yes   Have asthma Yes  
A Heart Transplant Yes        
Congenital Heart Disease Yes   Other health items - you:    
      Take Prescription Medicines Yes  
Symptoms you experience:     Take Heart Medications Yes  
Chest discomfort with exertion Yes   Are Pregnant Yes  
Unreasonable breathlessness Yes   Trying to Conceive Yes  
Dizziness, fainting, blackouts Yes        
Musculoskeletal problems Yes        

If you have any other special health needs please discuss these with your trainer.

  Agreement for participation in group fitness training


The trainer refers to the Australian Registered business fitness @ flagstaff.

I acknowledge that it is a condition of participating in this activity that I do so at my own risk. I accept all the risks and hereby indemnify and release the trainer, their agents, affiliates, employees, members and flagstaff community centre against all liability, claims, demands, and proceeding arising out of or connected with my participation in this activity.

This release and indemnity continues forever and binds my heirs, successors, executors, personal representatives and assigns. I acknowledge that participating in this activity may involve a risk of serious injury from various courses including: over exertion, dehydration, equipment failure and accidents with equipment and surroundings.

I recognise the difficulties associated with the activity and attest I am physically fit to participate safely in the activity and I understand the demanding physical nature of this activity. I am not aware of any medical condition, injury or impairment that will be detrimental to my health if I participate in this activity. A qualified medical practitioner has not advised me against moderate and vigorous activity.

In the event that I become aware of any medical condition, injury or impairment that will be detrimental to my health if I participate in this activity my trainer will be immediately informed. By continuing to participate in this activity, I accept the risks despite these conditions and am still, and will always be under the terms of this agreement.

I certify that I am 18 years or older and have read this document and fully understand it.