Member Pre-exercise Screening Questionnaire

This pre-exercise screening tool does not provide advice on any matter nor does it substitute for advice from an appropriately qualified medical professional. M.A. & C.B. Burke Pty. Ltd. (ACN 010 510 988) t/as Workout Indooroopilly (“Workout Indooroopilly”) gives no warranty of safety resulting from its use. The use of this pre exercise screening tool in no way guarantees or safeguards against any injury or death sustained as a consequence of undertaking activities in our facilities. No responsibility or liability whatsoever can be accepted by Workout Indooroopilly for any loss, damage, illness, injury or death that may arise from any person acting on any statement or information contained in this document.

IF YOU ANSWERED ‘YES’ to any of the 7 questions, please seek guidance from your GP or appropriate allied health professional prior to undertaking physical activity/exercise. Undertaking any form of physical activity or exercise has inherent risks, including physical injury and death, and you should carefully consider whether you are fit and able to undertake those activities before doing so. You are responsible for your own health and where you are uncertain as to your fitness and capability to undertake those activities you need to obtain proper advice and instruction before doing so. If you proceed to undertake those activities at Workout Indooroopilly without obtaining such advice you do so at your own risk.

IF YOU ANSWERED ‘NO’ to all of the 7 questions, and you have no other
concerns about your health, you may proceed to undertake light-moderate
intensity physical activity/exercise.

ACKNOWLEDGEMENT AND AGREEMENT

By ticking "I Agree" below and clicking the "Submit" button you acknowledge and agree that:

• I believe that to the best of my knowledge, all of the information I have supplied within this questionnaire is true and correct.
• I understand that Workout Indooroopilly may rely on the information that I have provided in this form.
• I also agree that should the information about my fitness or health contained in this form change after I have provided it to Workout Indooroopilly, it is my responsibility to obtain a further clearance from any medical professional before undertaking any exercise or activity at Workout Indooroopilly.

By ticking "I Agree" below and clicking the "Submit" button you acknowledge and agree that:

I believe that to the best of my knowledge, all of the information I have supplied within this questionnaire regarding my child’s health is true and correct.
I understand that Workout Indooroopilly may rely on the information that I have provided in this form.
I also agree that should the information about my child’s fitness or health contained in this form change, it is my responsibility to notify Workout Indooroopilly in writing of this change and to obtain a clearance or additional clearance from any medical professional or to understand any limitations or restrictions my child may be subject to before my child undertakes any exercise or activity at Workout Indooroopilly.
I give permission for my child to commence exercise and activity at Workout Indooroopilly.

Member name: {memberName}

Minimum Term: 4 weeks

Membership Term: Ongoing

Membership Start Date: {membershipStart}

Membership Fees (Per fortnight): $64.00

First Direct Debit: To be confirmed

Initial Payment: $0

An Activation Fee of $45 will be added to your first direct debit.

A Pro-Rata membership amount for the period from your membership start date ({membershipStart}) to the first direct debit date will be calculated and added to your first direct debit.

Billed Today: $0

Future Direct Debit Payments will be debited to your bank account or credit card.  We will contact you shortly to confirm these details.

By ticking "I Agree" below and clicking the "Confirm Purchase" button you acknowledge and agree that:
(a) You have read, understand and agree to the Workout Indooroopilly Membership Terms & Conditions, Direct Debit Terms & Conditions and the Privacy Policy (located on our website at www.workout.net.au);
(b) The information you have provided to Workout Indooroopilly is true and correct;
(c) You understand that you are signing up for a membership contract that requires among other things payment of membership fees;
(d) Prior to commencing any activities at Workout Indooroopilly you must complete a Health Questionnaire (Pre-exercise screening questionnaire) and where you have indicated you have any serious injury or medical condition it is recommended that you obtain a medical clearance. It is also recommended that you complete an onsite orientation with one of Workout Indooroopilly’s fitness professionals;
(e) Every time you use the Workout Indooroopilly facilities you will be in good physical condition and know of no medical or other reason why you cannot or should not do active or passive exercise.

Please ensure that your Member Details are kept up to date so that we can communicate important information regarding your membership and Club activities. Please read our Privacy Policy to understand how we collect, store and use your personal information. Our current Privacy Policy, Membership Terms & Conditions and Direct Debit Terms & Conditions can be located on our website at www.workout.net.au/policies-and-legal. You may also contact us at any time with any queries or concerns at info@workout.net.au.

By ticking "I Agree" below and clicking the "Confirm Purchase" button you acknowledge and agree that:

I {name16} being the parent or guardian of the member {memberName}, confirm that I have received, understood and agreed to the Workout Indooroopilly Membership Terms & Conditions, Direct Debit Terms & Conditions, and Privacy Policy and where the context permits, those will apply myself as if I too were a member of Workout Indooroopilly. By signing this application form I have agreed to indemnify Workout Indooroopilly against any claim or liability, of whatever nature, that I may bring or may be brought against Workout Indooroopilly, regarding or in connection with the member {memberName} while the member remains under the age of 18 years.

M.A. & C.B. Burke Pty. Ltd. (ACN 010 510 988) t/as Workout Indooroopilly
138 Witton Road, Indooroopilly QLD 4068
P: 07 3378 8950 E: info@workout.net.au