WeInclusive program Registration Form

WeInclusive program Registration
Your Information
Name

First NameLast Name
E-mail
What is your intention for joining this program?
Please tell us about your body
Are you currently being treated for any injuries or conditions?*

YesNo

If yes, please outline...

Have you had any major injury, condition or surgery in the past?*

YesNo
If yes, please outline...
Do you have any current undiagnosed pain?*

YesNo
Please explain location and severity (mild, moderate, severe)
Do you have any of the conditions below. Please select

AsthmaEpilepsyDiabetesHeart DiseaseOsteoporosisArthritisHigh/low blood pressureDizzinessChest painOther
Females only. Are you pregnant or had a baby in the last 12 months.*

Yes, I'm pregnantYes, I had a baby in the last 12 monthsNo
If so, how many weeks pregnant or post natal?
And your mind
Have you experienced one of the following in the last six months? Please select

AnxietyPanic AttacksDepressionFatigueNervous tensionInsomniaPhobiasChronic PainOther
Have you experienced significant trauma in your life? if yes, please describe.
Are you currently experiencing loss/grief? if yes, please describe.

How would you rate your current stress level?

	1	2	3	4	5

1 is Mild, 5 is Severe

Have you meditated before?

YesNo
Rate your level

BeginnerIntermediateAdvanced
Informed Consent and Acknowledgement

I give my approval for my participation in all activities prepared by WeInclusive during the duration of the program. I give my consent for the recording of the sessions. I will inform WeInclusive of any medical conditions/injuries that may prevent me from exercising, now, or during the program.

I am aware that while everything possible will be done to ensure my exercise program is safe and effective, I am choosing to exercise at my own risk. I am taking responsibility for my own body. I understand the risk of being injured that is inherent in all sports activities.

I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless WeInclusive and all its respective agents from all liability for injuries to me arising out of participating in the program.

In case of injury to me, I hereby waive all claims against WeInclusive, including all coaches and all participants.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature

Clear
Privacy Statement: Protecting your privacy and personal information is important to WeInclusive. It is however important for us to collect certain personal information from you in order to offer you effective and efficient service. We will only collect information from you with your knowledge and your consent, only use personal information provided by you for the purposes for which it was collected. This information is confidential and will not be disclosed to your employer. We will ensure that your personal information is not disclosed to other institutions except if required by law or other regulation and remove your personal information from our system where it is no longer required. You can gain access to the personal information we have about you and provide any necessary corrections by contacting Weinclusive emilie.perrot@weinclusive.com.au.
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