Personal Information

First Name:

Last Name:

Mobile:

Date of birth:

Gender Pronoun

Emergency Contact Details

It is vital that we have an emergency contact for you. This can be a relative, partner, friend, housemate or work colleague. Preferably in this country but another country is fine too.

Emergency Contact Name:

Emergency Contact Number:

How did you hear about us? (If you've been referred by a current member then please put their name)

Previous experience? (if any)

Medical Information

Do you have any form of heart condition and have been told to only do medically approved physical activity?

Do you have chest pain brought on by physical activity?

Have you ever lost consciousness or lost your balance as a result of dizziness?

Do you have a bone or joint problem that could be aggravated by the proposed physical activity?

If yes, please detail:

Are you currently on any form of medication that may effect your ability to take part in class?

If yes, please detail:

Are you aware, through your own experience or a doctor's advice, of any other reason for not exercising without medical approval?

If yes, please detail:

If you answered YES to one or more questions, you should seek medical advice before starting any more or new forms of exercise. You may still be able to do any activity you want as long as you start slowly or you may need to restrict your activities to those which are safe for you.

Do you have any other major medical or physical problems/ailments/injuries/disabilities?

If yes, please detail:

Agreement

I confirm that all the information I have provided above is correct to the best of my knowledge