EVO enrolment form
Street Address Line 2
e.g. (07) 4545 6666 or (04) 1111 2345
Email - to send Zoom links
Do you suffer from any health condition that would make it difficult to exercise?
Please briefly describe your condition and a member of our team will contact you to discuss your participation
On average, on how many days of the week do you participate in physical activity?
0 days per week
1 - 2 days per week
3 - 4 days per week
5 - 6 days per week
On average, do you participate in at least 150 minutes of physical activity each week?
How would you rate your balance?
1 is Very poor, 10 is Excellent
What do you want to achieve from this program? - you can select multiple options
Improved muscle strength
Improve aerobic fitness
Develop an exercise habit
I agree to voluntarily participate in the EVO sessions.
I understand that I am free to withdraw at any time.
I understand that evaluation data will be gathered for reporting and ongoing program development purposes.
I understand that my name will not appear in this data, and I will not be individually identifiable in publications or reports.
I consent to having this data collected.
I have read all the information carefully and I understand it.
I acknowledge and accept the risks associated with the testing and exercise in which I will participate.
I agree that I am exercising at my own risk and take full responsibility for my actions.
I agree to indemnify Burnie Brae Ltd and Healthy Connections as principle for all actions, costs, claims, charges, expenses, and penalties arising from my participation in activities conducted and organised by Healthy Connections.
I have had the opportunity to ask any questions which have been answered to my satisfaction.
I have read and understood the declaration above and consent to participation in the EVO program.
Should be Empty: