Powerhouse Registration
My name is Mel and I am a Mum of 2 boys, a Baby and Child first aid Educator, baby wearing consultant and owner of Pregnancy to Parenthood. WHAT IS POWERHOUSE? KangaPowerhouse is a program designed to educate, empower and equip women with tools to assist in strengthening the powerhouse of your body: Your Pelvic Floor. Many women have a weakened pelvic floor and suffer from symptoms such as leaking urine, passing wind involuntarily, reduced sensation during sex and the list goes on. It's common. But it's not normal and not something any woman should live with without seeking help. If you have a weak pelvic floor we always advise you to visit a women's health physiotherapist who will be able to do an assessment of your pelvic floor and come up with a plan for therapy. Endorsed and encouraged by Women's Health Physiotherapists, the KangaPowerhouse program can further help in improving the function of your pelvic floor. The program will teach you about the function of your pelvic floor, offer practical ways you can improve function and learn fun and effective exercises to connect with and strengthen your pelvic floor. Described as "Yoga for the Pelvic Floor" you will be empowered by this program and improve confidence in the function of your body, in a supportive and caring environment. PRICE: - 8 week course $128 (Due to the sensitive nature of the course, class sizes are strictly limited and enrolments must start at the beginning of the course) WHAT TO BRING: - Water bottle - Wear comfortable clothing - All equipment for class is supplied and cleaned after each class TERMS AND CONDITIONS: Health: All participants must be at least 6 weeks postpartum or 12 weeks postpartum if they have had a caesarean. Participants must disclose all medical and physical conditions relevant to the class to the instructor and notify the instructor of any changes during the program. Facilities: Please respect the venues rules/belongings and leave everything in a tidy manner. Please take all rubbish off the premises for your own disposal. The studio, Kangatraining and your instructor do not take responsibility for the loss or damage of your property, so please do not bring any valuables with you nor leave them in your car. Payment: Payment for term must be made at least 1 week prior to term beginning to secure your spot. We accept bank transfer, EFT and cash (please have correct change). Cancellations, Returns and Refunds: Once payment is received and enrolment is confirmed, no refunds or credits will be issued for cancellations after the first class of the term has commenced. Cancellations may be approved in extraordinary circumstances (eg pregnancy, physical injury) and are at the discretion of the trainer. If approved a $10 administration fee will apply. FOR FURTHER INFO: - Please contact Mel via email info@pregnancytoparenthood.com.au or via Facebook - Call or text me on 0401 198 860
Personal Details
Given Name:
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Surname:
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Email address
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Sign up to our email newsletter to receive special offers? (approx 1 email per term)
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Yes
No
Gender:
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Female
Male
Prefer not to say
Other
Date of Birth:
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Day
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Month
Year
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Street Address:
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Suburb:
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Postcode:
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Mobile Number:
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Emergency Contact Person Name:
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Emergency Contact Number
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Which class are you interested in attending?
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Monday 10am / Menai Kangatraining
Tuesday 9:30am / Menai Kangatraining
Wednesday 10am / Narellan Kangatraining (Fully booked)
Wednesday 12pm / Narellan Kangatraining
How did you hear about our classes?
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Health Professional
Kangatraining Australia Website
Facebook
Google
Referral
Other
Kangatraining Adult Pre-Exercise Screening and Health Questionnaire
AIM: To identify individuals with known disease, and/or signs or symptoms of disease, who may be at a higher risk of an adverse event during physical exercise. An adverse event refers to an unexpected event that occurs as a consequence of an exercise session, resulting in ill health, physical harm or death to an individual. The screening system in no way guarantees against injury or death. No responsibility or liability whatsoever can be accepted by Exercise and Sport Science Australia, Fitness Australia, Sports Medicine Australia, Exercise is Medicine or Kangatraining Australia for any loss, damage or injury that may arise from any person acting on any statement or information contained in this system.
1. Are you currently pregnant? (If pregnant, you can only participate in PreKanga)
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YES
NO
2. Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?
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YES
NO
3. Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?
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YES
NO
4. Do you ever feel faint, dizzy or lose balance during physical activity/exercise?
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YES
NO
5. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?
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YES
NO
6. If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months?
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YES
NO
7. Do you have any other conditions that may require special consideration for you to exercise?
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YES
NO
IF YOU ANSWERED ‘YES’ to any of these 7 questions, you MUST obtain written medical clearance from an appropriate allied health professional or medical practitioner prior to undertaking exercise.
Most recent type of birth:
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Vaginal
Caesarean
Assisted
Not Applicable
Have you ever seen a womens health physiotherapist?
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YES
NO
Other
When was your appointment and which clinic did you visit?
Can you briefly describe the outcome of that appointment?
Can you briefly describe your previous and current exercise activities?
Are you taking any medication? If so, for what condition?
Please tick if you suffer, or have suffered, from any of the following conditions:
Symphysis Pubis Dysfunction (pain in the central pubic area).
Carpal Tunnel Syndrome (wrist/finger/hand/ forearm including pain and/or numbness and/or tingling)
Upper back/neck/shoulder pain**
Incontinence (urinary or faecal): do you leak when you cough, sneeze or need to urinate or feel any vaginal heaviness/dragging/bulging?
Piles/Haemorrhoids or constipation
Varicose veins
Gestational diabetes
Joint pain**
Muscle pain**
Sacrum or sacroiliac joint pain (pain in the low mid back/ top of the buttocks)
Knee pain (side, front or back)
Coccyx damage or pain
Prolapse (uterine, bladder, rectum vagina)**
Episiotomy cut, painful Perineum or tear (degree is known)**
Caesarean wound discomfort or ongoing numbness
Buttocks/ sciatica/ Piriformis pain
Bleeding during or after exercise
Separation of your abdominal muscles (DRAM)
Breast health/ mastitis within the last 3 months
Nerve damage sustained from birth (Pudendal).
Anaemia or taking iron medication
Other
Have you been told you have any of the following conditions (please tick if it applies):
High blood pressure
High cholesterol
High blood sugar levels
Have you have spent time in hospital (including day admission) for any medical condition/ illness/ injury in the past 12 months
Any muscle, bone or joint pain or soreness that made worse by particular types of activity
Other
Is there anything else you believe your trainer should be aware of?
I acknowledge that to the best of my knowledge all the information I have supplied in this form is true and correct.
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YES
Kangatraining/ PreKanga/ KangaBurn/ KangaonWheel / KangaMix/ KangaTrail/ KangaPowerhouse 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 ay 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 indemnify and to keep indemnified, Kangatraining its servants and licensee, and each of them against all actions, costs, claims, charges, expenses, penalties, demands and damages whatsoever which may be bought or made by me or on my behalf.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.
Please SIGN below if you agree with the above terms:
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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 in compliance with the Information privacy principles established by the South Australian Privacy Committee.
By SIGNING below you give permission for this to occur.
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Photography Permission
Photographs may be taken during class and used for publicity and promotional purposes. Throughout classes you may have the opportunity to be photographed or filmed for Kangatraining publications, such as our website, newsletter, and social media or to promote Kangatraining in the form of flyers, posters or in newspapers and other media. We would like your permission to use photographs or film taken of you to be used for the above purposes.
Do you give permission for the use of photographs of yourself and your child for promotional and publicity purposes?
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Yes
No
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Thank you for your time in completing our Kangatraining forms. We look forward to meeting you soon!
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