Name *
Name
DOB
DOB
Phone
Phone
Emergency Contact
Emergency Contact
Emergency Contact Phone
Emergency Contact Phone
PART A: MEDICAL CONSIDERATIONS
Has anyone in your family under 60 suffered heart disease, stroke, raised cholesterol or sudden death? *
Are you on any prescribed medication *
Are you pregnant, planning on becoming pregnant or have you recently given birth *
Have you been hospitalised recently and/or are you receiving any treatment for any injuries or conditions *
Do you have any infections or infectious diseases? *
PART B : DO YOU HAVE OR HAVE YOU HAD?
Any heart conditions? *
Stroke *
Heart Murmur *
Chest Pain *
Hernia or Gout *
Stomach or Ulcers *
Arthritis *
Kidney or Liver Problems *
Diabetes *
Asthma *
Epilepsy *
High Blood Pressure *
Glandular Fever *
Raised Cholesterol *
Dizziness or Fainting *
Allergies / Epipen *
Do you smoke or have you recently quit *
NAME AS SIGNATURE (PARENT/GUARDIAN IF UNDER 16) *
NAME AS SIGNATURE (PARENT/GUARDIAN IF UNDER 16)
In the interest of your safety, if answered yes to any of the above questions in Part B, we recommend you consulting your doctor to obtain a clearance before starting regular exercise. Please sign here if you have cleared the above condition/s (if any) with your doctor:
PART D : PLEASE READ THE FOLLOWING ADVICE CAREFULLY
NAME AS SIGNATURE (PARENT/GUARDIAN IF UNDER 16) *
NAME AS SIGNATURE (PARENT/GUARDIAN IF UNDER 16)
I am aware that there are significant risks involved in all aspects of physical training. I understand that the reaction of the heart, lungs and vascular system to exercise cannot always be predicted with accuracy. I understand that there is a risk of certain abnormal changes occurring during or following exercise which may include abnormalities of blood pressure or heart rate; chest, arm or leg discomfort; transient light-headedness or fainting; and in rare instances, heart attack, stroke or even death. Excessive work can result (in rare cases) in exertional rhabdomyolosis. I should look for signs of excessive soreness, darkened urine, and pain in the kidney areas in the days following a particularly intense workout. While this type of injury is relatively rare, it can occur due to a number of factors, including (but not limited to) genetic predisposition or dehydration, that may be beyond the control of my trainer.I understand that the programs and classes offered by The Movement Fitness & Wellbeing are of a nature and kind that are extremely strenuous and can/may push me to the limits of my physical abilities. These risks include, but are not limited to: falls which can result in serious injury or death, injury or death due to negligence on the part of myself, my training partner, or other people around me, injury or death due to improper use or failure of equipment. I am aware that any of these above mentioned risks may result in serious injury or death to myself and or my partner/s. I willingly assume full responsibility for any and all risks that I am exposing myself to as a result of my participation in The Movement Fitness & Wellbeing programs/classes and accept full responsibility for any injury or death that may result from participation in any activity, class or physical fitness program. I herby certify that I know of no medical problems that would increase my risk of illness and injury as a result of participation in a fitness program designed by The Movement Fitness & Wellbeing. With my full understanding of the above information, I agree to assume any and all risk associated with my participation in The Movement Fitness & Wellbeing programs/classes. By signing this document, I acknowledge that I have voluntarily chosen to participate in a program of progressive, physical exercise. By signing this document, I acknowledge being informed of the strenuous nature of the program and the potential for unusual, but possible, physiological results including, but not limited to, abnormal blood pressure, rhabdomyolosis, fainting, heart attack, or death. By signing this document, I assume all risk for my health and well-being and hold The Movement Fitness & Wellbeing, as well as its owners, employees, and other authorised agents including independent contractors, harmless there from. I understand that questions about exercise procedure and recommendations are encouraged and welcome. I accept all responsibility for my health and any results, injury or mishaps that may affect my well- being or health in any way. I waive any claims, demands, causes of action or any claims for relief whatsoever against, and release The Movement Fitness & Wellbeing (as well as any of its owners, employees, or other authorised agents, including independent contractors) from any and all liability, claims and/or causes of action that I may have for injuries or other damages, arising out of participation in The Movement Fitness & Wellbeing activities, including, but not limited to the personal training / nutritional programs and programs/classes.
PART E : PHOTO/VIDEO RELEASE
NAME AS SIGNATURE (PARENT/GUARDIAN IF UNDER 16) *
NAME AS SIGNATURE (PARENT/GUARDIAN IF UNDER 16)
I hereby grant The Movement Fitness & Wellbeing permission to use my photograph/video image in any and all publications for The Movement Fitness & Wellbeing, including web site entries, without payment or any other consideration in perpetuity. I hereby authorise The Movement Fitness & Wellbeing to record, edit, alter, copy, exhibit, publish or distribute collectively, “Use” all photos and images. I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my photo appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph or video images. I hereby hold harmless and release and forever discharge The Movement Fitness & Wellbeing from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf of on behalf of my estate which may have or may have by reason of such Use or this authorisation.
PART F : IMDEMNITY
NAME AS SIGNATURE (PARENT/GUARDIAN IF UNDER 16) *
NAME AS SIGNATURE (PARENT/GUARDIAN IF UNDER 16)
I recogniSe that there is risk involved in the types of activities offered by The Movement Fitness & Wellbeing. Therefore I accept financial responsibility for any injury that I may cause either to myself or to any other participant due to his/her negligence. Should the above-mentioned parties, or anyone acting on their behalf, be required to incur attorney’s fees and costs to enforce this agreement, I agree to reimburse them for such fees and costs. I further agree to indemnity and hold harmless The Movement Fitness & Wellbeing, their principals, agents, employees, and volunteers from liability for the injury or death of any person(s) and damage to property that may result from my negligent or intentional act or omission while participating in activities offered by The Movement Fitness & Wellbeing. I have fully read and fully understand the foregoing assumption of risk, and release of liability and I understand that by signing it obligates me to indemnify the parties named for any liability for injury or death of any person and damage to property caused by my negligent or intentional act or omission. I understand that by signing this form I am waiving valuable legal rights. I have carefully read this Agreement and fully understand its contents. I am aware that this is a release and waiver of liability and sign it knowingly, voluntarily, and of my own free will.