Let’s make sure you stay safe

Please take a minute to fill out this quick form, as we will need some details.

Please also state the class and class dates you are interested in, we can then confirm availability.

The Health questions help us make sure you’re safe and comfortable

while getting the most out of your sessions!

Please note all information is kept safe and confidential.

Name

First Name

Last Name

Phone

(###)

###

####

Please tell us which class you are interested in so we can check availability:

Emergency Contact

First Name

Last Name

Emergency Contact No

(###)

###

####

Has your doctor ever advised you to only do physical activity that they recommend?

Do you feel pain in your chest when you do physical activity?

In the past month, have you had chest pain when not doing physical activity?

Do you lose your balance because of dizziness or ever lose consciousness?

Do you have a bone or joint problem (e.g., back, knee, or hip) that could be made worse by a change in physical activity?

Are you currently taking any prescribed medications for a chronic condition?

If you are taking prescribed medication, please give details

Do you have any of the following conditions? (Tick all that apply)

Asthma

Diabetes

Epilepsy

Pregnancy

High blood pressure

Other (please specify below

Other health conditions

Is there any reason not mentioned above that might affect your ability to safely participate in a fitness class?

Participant Declaration

I confirm that the above information is correct to the best of my knowledge.

I understand that I take part in the class at my own risk.

I agree to inform the instructor of any changes to my health or fitness that may affect my participation

Signature

Date