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Waiver - Crawley
First Name*
Surname*
Address*
Postal Code*
Date Of Birth*
Phone*
Email*
Membership Type*
Daily
Weekly
Monthly
Yearly
Personal Trainer*
Yes
No
Has your doctor advised against exercise & training?*
Yes
No
Are you pregnant or postnatal?*
Yes
No
Do you suffer from asthma or breathing difficulties?*
Yes
No
Have you been in hospital in the last 3 years?*
Yes
No
Are you taking any medication?*
Yes
No
Do you suffer from diabetes or epilepsy?*
Yes
No
Do you suffer from an allergy?*
Yes
No
Do you have a heart condition & should only do physical activity recommended by a doctor?*
Yes
No
Do you feel pain in your chest when you exercise?*
Yes
No
Have you had pain in your chest when not exercising?*
Yes
No
Do you lose your balance because of dizziness or lost consciousness?*
Yes
No
Do you have a bone or joint problem that could be made worse by exercise?*
Yes
No
Do you know of any other reason why you should not do physical activity?*
Yes
No
Do you require an induction?*
Yes
No
If you answered yes to any of the above, please provide details below:
Height*
Weight*
Emergency Contact Name/Number*
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