Registration form

Please complete this form, print it out, sign it and bring it with you to your first class (allow 10 minutes).

Name:

Address:

Telephone number:

Mobile number:

Email address:

Date of birth:

Health questions

1. Has your Doctor ever said you have a heart condition and that you should only do physical activity recommended by a Doctor?

Yes No

2. Do you feel pain in your chest when you exercise?

Yes No

3. In the past month have you had chest pain when you were not doing physical activity?

Yes No

4. Do you lose balance due to dizziness or do you ever lose consciousness?

Yes No

5. Do you have a bone or joint problem that could be aggravated by exercise?

Yes No

6. Is your Doctor currently prescribing drugs for your blood pressure or heart condition?

Yes No

7. Do you suffer from asthma, diabetes or epilepsy?

Yes No

8. Do you know of any other health reason why you should not exercise?

Yes No

If yes please state:

If you have answered 'yes' to any of the questions you should talk to your Doctor and gain approval before taking part.
If you have answered 'no' to all the questions then participating in the classes should be safe and effective. If your health changes or you feel unwell you should let us know.
If you have any doubts you should always ask the instructor.

Agreement of risk

I understand that the instructor will plan to teach each class safely. However, as with any physical activity there is a risk of injury and I agree to participate in any classes fully at my own risk.

Signature:

Date:

Please note your contact details will only be used by us to keep you up to date with class changes, promotions and offers.

Fitness Fusion
25 The Grove Promenade, Ilkley, West Yorkshire, LS29 8AF
Telephone: 01943 600 499 Email: fit@fitnessfusion.co.uk
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