Pre-Exercise Health Questionnaire

COVID-19

Please note that it is strongly recommended for all participants 16+ years of age to be at least double vaccinated to best protect yourself and the little ones. If you are unwell at all, please stay home and request a makeup session for when you are better or a recorded class to do at home.

What date do you wish to have your trial class? (Term 1 classes will resume February 8, 2023.)*

Date

Name*

First NameLast Name

Phone Number*

Email*

example@example.com

Have you previously attended a class with Kangatraining Liverpool? (If you've welcomed a new baby since filling out this form, please click "no" here.)*

YesNo

Gender

FemaleMaleOther

Your Date of Birth*

Date

Address*

Street Address

Street Address Line 2

CityState

Postcode

Emergency Contact Person*

NameRelation to you

Emergency Contact Phone Number*

How did you hear about Kangatraining?*

Please specify if you have one of the following pre-existing condition*

	Yes	No
Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?
Do you ever feel faint , dizzy or lose balance during physical activity/exercise?
Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months? (If so, you will need a current action management plan before commencing Kangatraining)
If you have diabetes (type I or II) have you had trouble controlling your blood glucose in the last 3 months?
Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?
Do you ever experience unexplained pains or discomforts in your chest at rest or during physical activity/exercise?
Are you currently pregnant? (If pregnant, you can only participate in Pre-Kanga)

Baby's Name

First NameLast Name

Baby's Date of Birth*

Date

Baby's current weight (approximate)*

Type of delivery*

VaginalCaesareanAssistedOther

Date of Post Natal Check up*

Date

Do you have a medical clearance to start exercise from your health professional (i.e. GP/OBGYN/Women's Health Physio)?*

Are you breastfeeding?*

Do you have any older children you plan to bring to class? I need to know for restricted head counts pertaining to physical distancing regulations. Please let me know their age and any concerns you may have about them attending our session.

Are you currently taking any medications? If so please also specify what they are prescribed for.*

Please briefly detail your past and current exercise levels.*

Please tick if you have ever experienced any of the following conditions:*

	Yes	No
Symphysis Pubis Dysfunction (pain in the central pubic area)
Sacrum or Sacroiliac Joint Pain (pain in the very lower mid back - top of buttocks)
Bleeding during or after exercising or any unexplained bleeding
Carpal Tunnel Syndrome (Wrist/finger/hand forearm - pain/numbness or tingling)
Knee Pain (Side, front or back)
Upper Back/Neck/Shoulder Pain
Coccyx Damage or Pain
Separation of your abdominal muscles
Incontinence (Urinary or Faecal)
Prolapse (Uterine, Bladder, Rectum, Vaginal)
Breast Health/Breastfeeding Issues/Mastitis within the last 3 months
Piles/Haemorrhoids/Constipation
Episiotomy Cut, Painful Perineum or Tears
Nerve damage sustained from birthing (Pudendal)
Gestational Diabetes
C-section wound discomfort or slow healing or ongoing numbness
Anaemia or taking iron medication
Joint/Muscle Pain
Buttock/Piriformis Pain/Sciatica
Varicose Veins
Other e.g. weak pelvic floor
High blood pressure
High blood sugar levels
High cholesterol
You have spent time in hospital (including day admissions) for any medical condition/illness/injury in the past 12 months (apart from childbirth)

If you have ticked 'yes' to any of the above conditions, it is recommended you seek guidance from an appripriate allied health professional prior to undertaking physical activity/exercise

Does your baby have any health/medical issues relevant to this class?*

	Yes	No
Hip Dysplasia
Contraindications to being in a sling? e.g. head control or neurological issues.
Other

If you ticked 'other' above to any health/medical issues for your baby, please explain:

Do you own a baby carrier? If yes, what type? (Please note some carriers are not appropriate for Kangatraining and you may be asked to use a hire carrier free of charge.)*

Unsuitable carriers for Kangatraining include, but are not limited to, stretchy wraps, ring slings, Baby Bjorn carriers, single shouldered carriers, carriers without waistbands, and those that may not support baby optimally. Final decision of carrier suitability will be at the trainer's discretion. Please ask if you are unsure if your carrier is suitable for class.

Have you experienced any problems using a baby carrier? If so, please detail:

Note: Not all carriers are suitable for Kangatraining, please see warning above.

Is there any other information you would like your Kangatrainer to be aware of?

In the chance that our classes are moved outdoors (pop-ups normally run outdoors, or if COVID worsens we may move outdoors); do you have any experience with the following?*

	Yes	No
Allergies to grass/pollen/pollution
Reaction to insect bites
Heat exhaustion/stroke
Anxiety about exercising in public

If you ticked 'Yes' to any of the above, please list details here. Otherwise do you have any other concerns about training in an outdoor environment?

Kangatraining Consent and Waiver

I hereby understand and acknowledge that the training, programs and activities provided by Kangatraining may expose me and/or my child to inherent risks including, but not limited to, accidents, injury, illness and death. I assume all risk of injuries associated with the participation including, but not limited to, falls, contact with other participants, use and hire of baby carriers, the effects of weather including heath and/or humidity, and all other such risks being known and appreciated by me.

I acknowledge my responsibility in communicating any physical and psychological concerns that might conflict with my own, or my child’s, participation in the activity. I acknowledge that I am physically fit and mentally capable of performing the physical activity I choose to participate in. I confirm that if I am pregnant I have received written consent from my doctor that I am able to participate in chosen activity. I confirm that where I have hired a baby carrier, that my child does not exceed the manufacturer’s recommended weight of 20kg.

After having read this waiver and knowing these facts, and in consideration of acceptable of my participation and Kangatraining furnishing services to me, I agree, for myself and anyone entitled to act on my behalf, to waive any responsibility, liabilities, demands, costs, or claims of whatsoever nature or cause including negligence, howsoever arising, which I might have, or which may arise against Kangatraining, its officers, agents, employees, organisers, representatices, and successors.

I undertake to indemnify and hold harmless and free, Kangatraining and its licensees, from any and all claims of whatsoever nature or cause (including negligence) and however arising, which may be made by myself or anyone else on my behalf who suffer any damages (including but not limited to damages arising from or related to personal injury, death and/or loss of support) of whatsoever nature. I agree to comply with all the rules, regulations and instructions in relation to the chosen activity.

I have read and understood the content and important consequences of this document and acknowledge that I am bound thereby.*

Virtual Class Disclaimer

You should understand that when participating in any exercise or dance program, there is the possibility of physical injury.

If you engage in any of our online programs, you agree that you do so at your own risk, are voluntarily participating in these activities, assume all risk of injury to yourself, and agree to release and discharge Kangatraining Australia from any and all claims or causes of action, known or unknown, arising out of Kangatraining Australia negligence.

If wearing your baby, it is solely your responsibility to ensure the carrier is optimal, correctly fitted and safe for the activity you are partaking in.

I have read and understood the content and important consequences of this document and acknowledge that I am bound thereby.*

Privacy Statement

The personal information contained in this document is to provide contact information and medical details for individuals wishing to undertaking exercise/activity with Kangatraining. This information may be disclosed to medical practitioners or designated third parties should there by an issue or emergency, and in accordance with the Information Privacy Act 2009 (QLD) and The Privacy and Personal Information Protection Act 1998 (NSW) and Privacy Act 1998 (WA) and Information Act 2002 (NT) and Freedom of Information Act 1982 (VIC) and Personal Information Protection Act 2014 (TAS) and in compliance with the Information privacy principles established by the South Australian Privacy Committee. By signing you give permission for this to occur.

By signing this, I give permission for this to occur*

Photographs may be taken during class and used for publicity and promotional purposes. Do you give permission for the use of photographs of yourself for promotional and publicity purposes?*

YesNoOther

Photographs may be taken during class and used for publicity and promotional purposes. Do you give permission for the use of photographs of your child for promotional and publicity purposes?*

YesNoOther

Have any circumstances changed since your last booking (health of you or bub, new bub, your health, carrier, etc.)?

YesNo

My Products

Class Options (*Please note payment will be made by invoice sent via email. Your spot in class is only secured once payment is received.)

Trial Class$15AUD

Your very first Kanga class! Free carrier hire (if needed).

Me Time (1 class x week)$136AUD

$17 per week, adjusted where needed, just chat to me! One class per week. Free carrier hire (if needed).

Casual Class$20AUD

No term commitment. Bookings subject to class availability. Free carrier hire (if needed/available).

Outdoor Pop-up Special$10AUD

Normally during NSW School Holidays

Carrier Hire (Optional)

Free Carrier Hire (if required)$ FreeAUD

Total $0.00AUD

Pre-Exercise Health Questionnaire

Term 1, 2023

If you answered 'Yes' to any of these 7 questions, you MUST obtain written medical clearance from an appropriate health professional prior to commencing Kangatraining.