CHARITY BOOT CAMP - HEALTH FORM QUESTIONNAIRE
Charity boot camp hosted by Blitzfit Australia & Perception Fitness
Let's start with your name!
How did you hear about our charity boot camp?
Blitzfit Member (please type person's name in ÖTHER field below)
Jodie @ Perception Fitness
Your mobile number
Your email address (don't worry, we won't spam you, this is just so we can email you info about the charity boot camp!)
Your birthday (day/month/year)
What do you think your current fitness level is?
Are you currently exercising at the moment?
If you are currently exercising, what sort of exercise are you doing and how often each week do you do this?
Do you have a friend who you think would like to join you at our charity boot camp?
HEALTH ASSESSMENT - Do you suffer from, or have you ever suffered from any of the following:
High or low blood pressure
Heart palpitations/chest pain
Any infections or infectious diseases
Any major injuries
Females: Have you been pregnant recently
If you answered "Yes" to any of the above questions, please explain condition(s).
If you answered "YES" to any of the above questions, please advise whether you are cleared by your Doctor to exercise. Please note, if your GP or health professional has NOT given you the all-clear to exercise, for your own safety you will not be able to participate in the charity boot camp.
Yes I am cleared by my Dr to exercise
No I am not cleared by my Dr to exercise
YOUR EMERGENCY CONTACT'S NAME:
YOUR EMERGENCY CONTACT'S RELATIONSHIP TO YOU:
YOUR EMERGENCY CONTACT'S PHONE NUMBER:
By ticking the YES box below, I warrant to Katherine Gorrie that all information provided on this form is true and correct. I accept that I will not have any claim or any nature against Katherine Gorrie and/or any trainers contracted under her business and/or any trainers assisting in the charity boot camp on 4th May 2019 for any illness, injury or adverse change in medical condition or state of health arising directly or indirectly from any program or advice provided by or carried out preparatory to or as part of any program I undertake whilst under the supervision or instruction of Katherine Gorrie and/or any trainers contracted under her business and/or any trainers assisting in the charity boot camp on 4th May 2019. Any rights granted to me by law which are not capable of change by agreement remain unaffected by the terms of this agreement.
By selecting YES, I agree to the above.
PLEASE CLICK HERE TO SUBMIT
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