Membership Agreement Health Camp (Please Fill in and Bring with You)
Membership Agreement – Health Camp (Please fill in and Bring with You)
Member Details
Surname ______Name ______
Title ______Date of Birth ______
Home Address ______
Home Telephone Number ______Mobile ______
Email Address ______
I have read the terms and conditions, signed the par-q questionnaire and risk disclaimer and have received a copy of them.
9. Testimonials
FHS Ltd, with the client’s permission, use photo based and verbal testimonials in their promotional literature. We would ask that if you wish for your PHOTO testimonials to remain private then please initial here _____
10. More information
If you wish to receive a monthly hard-copy newsletter from us in addition to email updates then please intital here______
10. Participation subject to Waiver and Risk Disclaimer
In consideration of gaining access to participate in activities associated with Fitness and Health Services I do hereby waive, release and forever discharge Fitness and Health Services its officers, agents, employees, representatives, executors, and all others from any and all responsibilities or liability for injuries or damages resulting from my participation in any activities in said program.______(Please initial)
I understand the policies and procedures set forth by Fitness and Health Services and I have had the opportunity to discuss my specific needs in relation to participatory activity and, as a result, I do voluntarily request the right to participate in this preventive program of exercise. ______(Please initial)
Also, in consideration of the above factors, I acknowledge the existence of risks in connection with these activities, assume such risks and agree to accept the responsibilities for any injuries sustained by my participation in the course via the use of the facilities and/or its equipment. Most specifically, I acknowledge and accept responsibility for injuries arising out of those activities, which involve risk in any of the following areas
ü The use of facility equipment
ü The performance of fitness-related evaluations to assess functional capacity
ü The participation in group activities related to exercise and activity
ü Incidents that occur within the institution facility, locker rooms, dressing rooms, showers, and other areas associated with Fitness and Health Services Ltd
In addition, it was seriously recommended that I consult with a physician before engaging in any activities associated with Fitness and Health Services.
Having read the preceding, I acknowledge full understanding of those risks set forth herein and knowingly agree to accept full responsibility for my own exposures to such risks and to waive full responsibility and liability on behalf of Fitness and Health Services Ltd.
During your exercise programme, every effort will be made to assure your safety. However, as with any exercise programme there are risks including increased heart stress and the chance of musculoskeletal injuries. In participating in this programme you agree to assume responsibility for these risks and waive any possibility for personal damage. You also agree that, to your knowledge, you have no limiting physical conditions or disability that would preclude an exercise programme.
A physician’s examination is recommended for 1) all participants with any exercise restrictions; and 2) all persons over 40 years of age. Personal training participants in either or both of these categories who do not have a prior physical examination must acknowledge they have been informed of its importance. By signing below, you accept full responsibility for your won health and well-being and you acknowledge an understanding that no responsibility is assumed by the leaders of the programme.
Signed (Client) ______
Signed ( Sphere Fitness Studio) ______
Date ______
Section A
Please take the time to complete this Health Status Questionnaire. This information will enable your Fitness Instructor to ensure your Fitness Programme is specific to you and your needs. Your Instructor can ensure that you are exercising safely and help you achieve your goals. Your answers will be kept strictly confidential.
Please answer each question in full by ticking the appropriate response.
YES NO
YES NO YES NO
1. Are you currently under the care of a doctor or other health care professional for any reason?
If yes, please specify:
If yes, is your doctor aware that you are going to participate in an exercise program?
2.
Do you presently take any medications or supplements, either prescription or over the counter?
If yes, please specify:
3.
YES NO
YES NO
YES NO
For women only:
a. Are you currently pregnant?
b. Have you had a baby within the last three (3) months?
4.
Do you have any allergies, including any allergies to medication?
If yes, please specify:
5.
Have you ever suffered from, or do you currently suffer from:
a. High blood pressure? YES NO b. Heart disease or any other heart condition? YES NO
c. Diabetes? YES NO d. High cholesterol? YES NO
Please elaborate on the 'YES' answers:
6. Have you ever been treated for, or has a doctor ever told you that you have:
a. Asthma? YES NO b. Dizziness, light-headedness, or faintness? YES NO
c. Arthritis? YES NO d. Spine, disc, or lower back problems? YES NO
e. Back, joint or muscle pain? YES NO
Please elaborate on the 'YES' answers:
Section B
- Have you undertaken regular exercise recently?
If yes, please specify:
YES NO
2. Do you now, or have you ever smoked?
If yes, please indicate the amount and the length of time: If you have stopped, for how long:
YES NO
YES NO
3.
YES NO
Have you ever been hospitalised for any reason within the last five (5) years?
If yes, please specify:
4.
YES NO YES NO
Have you ever had surgery?
If yes, please specify:
5. Has any family member had:
a. Heart disease YES NO
c. High Blood Pressure? YES NO
b. Diabetes?
d. High cholesterol?
If you have answered 'YES' to any of the above please indicate the family member and the nature of illness:
6. Do you suffer from, or have you been treated for any conditions or diseases, which have not been previously listed on this questionnaire? YES NO
If yes, please specify:
7. Do you feel that there is any other information, which might be valuable in assessing your current health status? YES NO
If yes, please specify:
8. Is there a good physical reason that might cause you to limit your activities, or should be taken into consideration when developing your exercise program? YES NO If yes, please specify:
If you answer 'YES' to two or more of the questions in Section A a G.P.'s clearance is required. If you answer 'YES' to any of these questions, an instructor must evaluate.
Signature ______Date ______
Instructor Signature ______Date ______