top of page

Health Declaration

Please fill out the following form in order to participate in our programs & classes.

Date of birth
Day
Month
Year

Please be aware that our Fitness Instructors have no expertise in the field of medicine nor are they trained to detect serious medical problems. If you have any specific medical concerns, conditions or requirements you are advised to consult your Doctor before participation as to what specific restriction, if any, should apply to your condition and which activities and or exercises you should avoid. You are solely responsible for evaluating and assessing your own health and wellbeing and whether, in all the circumstances, you should access and use facilities and participate in classes.

Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?
Yes
No
Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?
Yes
No
Do you ever feel faint or have spells of dizziness or lose balance during physical activity/exercise?
Yes
No
Have you had an asthma attack requiring immediate medical attention at any time over the last twelve months?
Yes
No
If you have Diabetes (type I or type II) have you had trouble controlling Blood Glucose levels in the last 3 months?
Yes
No
Any diagnosed muscle, bone or joint problems that could be made worse by physical activity/exercise participation?
Yes
No
Are you aware of any other medical conditions that may require special consideration for you to participate in physical activity/exercise?
Yes
No

If you have answered YES to any of the seven questions above, you are required to seek medical clearance from an appropriate allied health professional or medical practitioner prior to undertaking any exercise.

Do you or have you suffered from the following diseases or conditions? If yes, please specify details.

Asthma / respiratory problem?
Yes
No
Epilepsy / seizures?
Yes
No
Joint / arthritis / bone disorders?
Yes
No
Cancer?
Yes
No
Muscular / ligament injuries?
Yes
No
Mental health disorders?
Yes
No
Angina / heart condition or disease?
Yes
No
Dementia?
Yes
No
Family history of heart disease?
Yes
No
Back pain / herniations?
Yes
No
Heart attack / stroke?
Yes
No
Are you diabetic?
Yes
No
Cholesterol concerns?
Yes
No
Blood pressure concerns?
Yes
No
Vision / hearing problems?
Yes
No
Faintness/lightheadedness/blackouts/headaches?
Yes
No
Disability (intellectual or physical)?
Yes
No
Do you have any allergies?
Yes
No
Other conditions that might restrict exercise?
Yes
No

Physical activity


Do you currently exercise?
Yes
No
How often do you exercise?
Never
1-2 times a week
3-4 times a week
5-6 times a week
More than 6 times a week
What is the average duration of your exercise session?
Less than 30 minutes
30-60 minutes
60-90 minutes
More than 90 minutes
What is the average intensity?
Light
Moderate
Vigorous / high

Please provide an indication of your goals and preferences

Increase cardiovascular fitness
Very important
Somewhat important
Not important
Lose weight
Very important
Somewhat important
Not important
Increase strength
Very important
Somewhat important
Not important
Social - participate in group activities
Very important
Somewhat important
Not important

Sign & release

1. In consideration of participating in group training "Activity", I agree and acknowledge that I am fully aware that participation in the Activity involves risk and I accept all the risks of participating, even if the risks are created by the carelessness, negligence or gross negligence of a Released Party (as defined below) or anyone else.


2. "Claims" include but not limited to any and all liabilities, claims, demands, legal actions, rights of actions for damages, personal injury or death in connection with participation of the Activity. "Released Party" means all of the Activity participants, volunteers, instructors.


3. I agree and acknowledge that:

a. I am in proper physical condition to participate in the Activity and am aware that participation could, in some circumstances, result in physical injury, serious physical injury or death.

b. I understand my physical limitations and am sufficiently self-aware to stop the Activity before I become ill or injured.

c. I am aware that the Activity can occur outdoors, the streets adjoining the area of the Activity are open to regular vehicular traffic during the Activity times and I will obey all traffic laws and regulations.


4. I accept full responsibility for any equipment or technology loaned to me as part of participation in this Activity and commit to return the same in good working order.


5. I hereby, for myself and for my heirs, next of kin, executors, administrators and assigns, fully release, waive and forever discharge any and all rights or Claims I may have, now or in the future, against any Released Party, even if the Claims are based on the carelessness, negligence or gross negligence of a Released Party or anyone else. Without limiting the foregoing, I further release any recourses which I may now or hereafter have resulting from any decision of any Released Party.


6. I agree not to sue any Released Party for Claims, even if the Claims arise from the carelessness, negligence or gross negligence of any Released Party or anyone else. I agree to indemnify (reimburse for any loss) and hold harmless each Released Party from any loss or liability (including any reasonable legal fees they may incur) defending any Claim made by me or anyone making a Claim on my behalf, even if the Claim is alleged to or did result from the carelessness or negligence of any Released Party or anyone else.


7. I am aware that there is no obligation for any person to provide me with medical care during the Activity. I understand and acknowledge that:

a. there may be no aid stations available for the Activity

b. if medical care is rendered to me, I consent to that care if I am unable to give my consent for any reason at the time the care is rendered.


8. I am aware that it is advisable to consult a physician prior to participating in the Activity. If I have consulted a physician, I have taken the physician's advice.


9. I grant my permission to the Released Party and any transferee or licensee or any of them, to utilise any photographs, motion pictures, videotapes, recordings and other references or records of the Activity which may depict, record or refer to me for any purpose ("Likeness"), including commercial use by the released parties, their sponsors and their licensees. This permission is for the use anywhere in the world and on the Internet and for the unlimited period of time. I understand and agree and I will not be compensated or receive additional consideration for consenting to the use of my Likeness and that I will not be given a chance to receive, inspect or approve the promotional or marketing material, messages and/or content that may use my Likeness.


10. No warranties or representations have been made to me about the Activity which are not stated on this form. I understand and intend that this document act as the broadest and most inclusive assumption of risk, waiver, release of liability, agreement not to sue and indemnity.


11. If the provision of this agreement shall be unlawful, void or for any reason unenforceable, then that provision shall be deemed severable from this agreement and shall not affect the validity and enforceability of any remaining provisions.


12. I have fully read and understand this agreement. I am aware that by signing this agreement, I am waiving certain legal rights I or my heirs, next of kin, executors, administrators and assigns may have against the Released Party.


13. I hereby acknowledge that I may be required to use an automobile to travel to and from the Activity or as part of the Activity. I hereby acknowledge that I have the authority to use such automobile and that the automobile is fully insured for use in the Activity. I accept full responsibility for the automobile and that use of the automobile in the Activity will be at my own risk.

I also understand that:

All payments are non-refundable or transferrable for any reason, including, but not limited to vacation, illness and injury.
I agree
The scheduling and content of activities may be changed on occasion.
I agree
I will notify instructors immediately of any pain and/or major discomfort felt during any activity.
I agree
If I am pregnant or plan to become pregnant during the course of the Activity, I will submit a ParMED-X for Pregnancy, a guideline for health screening prior to participation in a fitness class.
I agree
Please upload any supporting documents or files

BY SIGNING BELOW, Participant accepts and agrees to the terms and provisions contained in the agreement.

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
Declaration
bottom of page