Junior Pre Exercise Questionnaire

Emergency Contact Information:

Please ensure is different to the Parent/Guardian above
Name*

First NameLast Name
Contact Number*
Do you give permission for you child's photo to be taken and used for promotional purposes?*

YesNo
I, the undersigned, consent to my child’s participation in the fitness program. I understand that the program will be conducted under the supervision of qualified staff and that any physical activity carries some inherent risk of injury.*
I, the undersigned acknowledge that I have provided accurate health information and that I will notify the program leaders of any changes in my child’s health status.*
Parent/Guardian Signature*

Clear
Should be Empty:

Health Information: