Make a Change Fitness

Client information
Full name

First NameLast Name
Birth Date

DayMonthYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Phone Number

Area CodePhone Number
Emergency contact

First NameLast Name
Phone number

Area CodePhone Number
Health questionnaire

Make a Change Fitness Pre-Screening
Common sense is your best guide when you answer this questionnaire. Please read the questions carefully and answer each one honestly: check YES or NO.

Par-Q

Rows	Yes	No
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose balance because of dizziness or do you ever lose consciousness?
Do you have bone or joint problem (for example, back, knee, or hip) that could be worsen by a change in your physical activity?
Do you have high/low blood pressure?
Do you have Asthma?
Do you have Diabetes?
Do you have Epilepsy?
Have you been hospitalized in the last 12 months?
Have you been cleared to exercise?

For the ladies - About you

Rows	Yes	No
Are you pregnant?
Have you recently (or ever) had a baby?
Are you breastfeeding?
Are you going through or have been through menopause?
Have you ever injured you pelvic region?
Do you have a chronic cough or sneeze?
Do you frequently lift heavy weights at work?
Do you have a history of lower back pain?

For the ladies - Do you

Rows	Yes	No
Accidentally leak urine when you exercise, laugh, cough or sneeze?
Need to get to the toilet in a hurry - or not make it?
Constantly need to go to the toilet?
Have a prolapse?

I have read, understood and completed this questionnaire. Any questions I had I asked and were answered to my full satisfaction.
Initials
Client Liability waiver
I am aware of the risks in participating in the activities offered and sponsored by Make a Change Fitness and I understand that all outdoor fitness that I will execute and participate in are entirely at my own risk and perils.

I recognise that exercise is not without varying degrees of risk to musculoskeletal and/or cardiorespiratory systems. I also understand that all session will be outdoors. I hereby certify that I know of no medical problems that would increase my risk.

I assume complete responsibility and liability for those risks and for the injuries that may occur as a result of these risks, even if injuries occur in a manner that is not foreseeable at the time I sign this agreement.

I realise that by voluntarily assuming the risks involved, I will be solely responsible for any loss or damage I sustain, including personal injuries to me, damage to my property, or damage arising out of my death.
Initials
Booking & Cancellation policy
Packages:
Bookings:

All bookings are made on Make a Change Fitness VIP Members Facebook group. A post will be posted on the group at 17:00 the day prior and you are required to comment which session you will be attending by 20:00 the night before.

Max of 12 people per session.

Cancellation:

Unfortunately there will be no refund for change of minds or missed sessions once the start of term challenge has commenced.
Initials

Billing policy
Payment is required prior to the commencement of all sessions via direct debit to the below Make a Change Fitness bank account.

Account Name: Make a Change Fitness

BSB# 062 692

A/C# 42610436

If you decide to go on one of Make a Change Fitness weekly packages, Make a Change Fitness use GO CASHLESS direct debit.

GO CASHLESS direct debit will come out of your bank account weekly.

Please note there will be a small transaction fee each week.

GO CASHLESS will send an email to set up your direct debit account prior to starting with Make a Change Fitness.

So no one needs to have the awkward conversation about money owing. All sessions at Make a Change Fitness require payment up front thank-you.
Initials
Client Signature
Signature
Date

JourMoisAnnéeHourMinutesAM/PM Option
Should be Empty:

Client information

Health questionnaire

Client Liability waiver

Booking & Cancellation policy

Billing policy

Client Signature