Name
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First Name
Last Name
Email
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Phone Number
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Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth
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MM
DD
YYYY
Age
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Emergency Contact
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First Name
Last Name
Emergency Contact Phone Number
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GP Surgery
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What service are you filling out the screening form for?
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Gym
Classes
Personal training
FREE Chat and consultation
Free Class Trial
Postnatal Course
Pregnancy Fitness
Other
Other - Please State
Have you ever had any of the following?
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If yes please provide more detail in the comments box below
If you answered yes or other please provide further details or add any issues not in the above list.
Please list any medications you are taking and why they have been prescribed
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Coronary Heart Disease Primary risk factors
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Please tick all that apply
Coronary Heart Disease Secondary Risk Factors
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Any clients that fall into one or more of the following categories should see their GP for medical clearance prior to testing and exercising.
• Any clients 35+ with one major risk factor
• Any client under 35 years with two major risk factors
If you ticked any of the boxes on the above two questions: Please give further details
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Do you know of any other reason why you should not take part in a physical activity program?
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Informed consent and Waiver
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I hereby state that I have read understood and answered honestly the screening questionnaire. During the exercise program, every effort is made to keep the class / session safe and minimise the risks whilst providing an effective session. I am participating of my own free will and I am aware, as with any exercise program, there is a risk of injury. I agree to participate in the exercise program described to me by Kate Campbell and the Kate Campbell Fitness Team I understand that for the session to remain safe, alternatives and adaptations will be made throughout. The structure, purpose, benefits, and risks of the session will be explained throughout the class, and I understand that I may withdraw from the session at any time. I understand it is my responsibility to inform Kate Campbell fitness team if any physical / Medical changes occur which may prevent me from exercising safely. If at any time you feel undue pain or excessive discomfort, Stop the activity, and inform instructor. I understand that from time-to-time photographs will be taken for advertising and promotion, and I agree to have any pictures of me used in this way. I will not hold KATE CAMPBELL FITNESS or team liable in any way for injuries or illness that may occur while I am training. I voluntarily agree to assume all the foregoing risks and accept sole responsibility for any injury to my myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my attendance at Kate Campbell Fitness. On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless Kate Campbell Fitness employees, Freelance instructors and self-employed personal trainers, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs, or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of Kate Campbell Fitness, its employees, Freelance instructors and self-employed personal trainers’ agents, and representatives, before, during, or after participation in any Kate Campbell Fitness programme.
Terms and conditions
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By ticking this box, I have read and agreed to the terms and conditions (available in the page footer)
