She's Active Joining Form
Bump * Baby * Beyond
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Emergency name and contact details
*
Please include name and phone number
Antenatal Information
Please complete this section if you are currently pregnant
Baby due date DD/MM/YY
Please indicate any risk factors associated with your pregnancy (please select those which apply)
Multiple Pregnancy (twins/triplets)
Gestational Diabetes
Placenta Previa
Preeclampsia
Previous Pre-term Labour
Placental Abruption
Premature Rupture of Membranes
IVF
Is this your first child?
Yes
No
Postnatal Information
Please complete this section if you have had a baby
Date of postnatal check (with youngest child) DD/MM/YY
If over a year ago please give a good guess/if never please input 01/01/2000
Names and age of children attending class
What type of delivery did you have?
Vaginal
Elective caesarean section
Emergency caesarean section
Details of pregnancy, delivery and postnatal recovery
Postnatal recovery (please select those which apply)
Pelvic Girdle Pain
Pelvic floor Dysfunction (eg, incontinence or urgency to use the toilet)
Prolapse
Core weakness
Perennial cut/tear
C - Section wound discomfort
Lower back pain
Sciatica pain
Unexplained vaginal bleeding
Perinatal mental health illness
other
If you have ticked any of the above, please give details
Medical History
Have you ever experienced any of the following? (please select those which apply)
Headaches
Dizziness or fainting
High / low blood pressure
Chest Pain
Currently pregnant
Covid-19
other
If you ticked any of the above please give details and include any other previous medical history you think may be important for She's Active to know about to help you on your fitness journey
Do you know of any reason why you should not engage in physical activity?
*
Yes
No
Exercise frequency
*
None at all
1-2 times per week
More than 3 time per week
What goals would you like to achieve with She's Active?
In order to keep you updated with class information, we may need to contact you from time to time. In accordance with GDPR, we require consent to contact you by each method, so please check the boxes below to indicate your consent (please select all that apply)
*
Text
Email
Phone
Please tick the box below if you’d like to be added to our mailing list to be kept up to date with all the latest at She's Active
I’d like to join the mailing list
Sometimes during classes, photos and videos are taken to be used on Social Media and other marketing channels, please tick here to give consent
*
I consent
I do not consent
Please tick here to confirm you have read and understood the Terms and Conditions (available from your instructor)
*
I have read the terms and conditions
Please confirm the information you have given is accurate
*
I agree
Whilst She's Active will endeavour to ensure the safety of all participants, exercise does come with some risks and She's Active will not be held responsible for any injury or damages incurred. Should your medical or fitness needs change throughout your time with She's Active, it is your responsibility to inform your instructor
*
I understand and accept the above statement
Submit
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