WABC - Membership Form 2020/2021

Registration Form

www.ourpowerhub.org
Members Details
First name*
Surname*
Address (Line 1)*
Address (Line 2)*
Post Code*
Date of Birth*

MonthDayYear
Date
Emai Address*
Contact Number*
Emergency Contact
Name*
Relationship*
Contact Number*
Exercise Readiness Questionnaire
Have you ever been advised by your GP/Doctor, not to undertake exercise?*

YESNO
Do you have a bone or joint problem that could worsen by undertaking exercise?*

YESNO
Do you suffer from spells of dizziness or feeling feint?*

YESNO
Do you ever get chest pains, caused by exercise or high intensity tasks (i.e. cleaning) ?*

YESNO
Have you ever had high blood pressure?*

YESNO
Are you currently taking any medication?*

NOYES
Are you pregnant, or have had a baby in the last 6 months?*

YESNO
Is there any other information, reason or cause which may affect you whilst exercising?*

YESNO
Any other information (Include medication, injuries, surgery etc - please write CLEARLY)
Ethnic Group

ArabAfricanBangladeshCaribbeanChineseWhite BritishWhite IrishWhite & AsianWhite & Black AfricanWhite & Black CaribbeanSudaneseSomalianMoroccanPakistaniIndianMixedAfghaniItalianSpanishOther
Please specify
Where did you first hear about Our Power Hub's services?

Social MediaFamily/FriendsNHS ServicesWord of MouthOther
MEDIA: I would like to be included in media for club promotional purposes - including, but not limited to photography, video, audio or print. I understand that from time to time the club will give the rights to third parties for editorial and broadcasting purposes (this applies to all media).*

NOYES
Member Declaration:

I agree to abide by the ‘Rules and OPH's Values

The information I/we have provided is true and accurate to the best of my knowledge.

All participants under the age of 18 years must obtain parental/adult consent prior to participation.
DECLARATION - Member*
DECLARATION - Parent/Guardian (for members under 18 years of Age)
DATE:*

DayMonthYear
Date
Should be Empty:

Registration Form