Waiver - Croydon

First Name*

Surname*

Address*

Postal Code*

Date Of Birth*

Phone*

Email*

Membership Type*

Daily

Weekly

Monthly

Yearly

Personal Trainer*

Yes

Has your doctor advised against exercise & training?*

Yes

Are you pregnant or postnatal?*

Yes

Do you suffer from asthma or breathing difficulties?*

Yes

Have you been in hospital in the last 3 years?*

Yes

Are you taking any medication?*

Yes

Do you suffer from diabetes or epilepsy?*

Yes

Do you suffer from an allergy?*

Yes

Do you have a heart condition & should only do physical activity recommended by a doctor?*

Yes

Do you feel pain in your chest when you exercise?*

Yes

Have you had pain in your chest when not exercising?*

Yes

Do you lose your balance because of dizziness or lost consciousness?*

Yes

Do you have a bone or joint problem that could be made worse by exercise?*

Yes

Do you know of any other reason why you should not do physical activity?*

Yes

Do you require an induction?*

Yes

If you answered yes to any of the above, please provide details below:

Height*

Weight*

Emergency Contact Name/Number*