Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Emergency Contact *

Parents or guardians name

First Name

Last Name

Have you ever had any of the following? *

If yes please provide more detail in the comments box below

Arthritis

Asthma - bring inhaler to session

Back Problems

Balance problems

Diabetes

Do you have a bone or joint problem that could be made worse by physical activity?

Do you have any allergies?

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

Hay fever

Heart Problems

High/low blood pressure

In the past month, have you had any chest pain while you were not doing any physical activity?

Disordered eating Now or in the past

Is your GP currently prescribing medicine for your blood pressure or heart condition?

Muscular aches or pains

On-going treatment from a Physio, Chiropractor or Osteopath

Sports injury now or in the past

Undergone surgery in the last 12 months

Other

None of the above

Informed consent and Waiver *

I hereby state that I have read understood and answered honestly the screening questionnaire. During the exercise programme, 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 programme, there is a risk of injury. I agree to participate in the exercise programme described to me by Kate Campbell and the Kate Campbell Fitness Team I understand that in order 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 staff 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 staff liable in any way for injuries or illness that may occur while I am training.

I agree

Parents or Guardians have read and agree

Terms and conditions *

By ticking this box I have read and agreed to the terms and conditions (available in the page footer)

Yes

Parents or Guardians have read and agree