Adult Trial Form

Members Name*

First NameLast Name

Date of Birth*

DayMonthYear

Age yrs: *

Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Emergency Contact Details*

First NameLast Name

Emergency Contact Mobile*

Please enter a valid phone number.

How did you hear about us?*

Do you have an previous Martial Art experience*

YESNO

What Martial Art do you have experience in?*

How long did you participate in the above Martial Art for?*

What rank do you hold in the Martial Art listed above?

if applicable

Which Martial Arts Classes would you like to trail? Select all that apply*

Please select the date you would like to come in for your first trial class

Date

PRE EXERCISE SCREENING TOOL

This screening tool does not provide advice on a particular matter, nor does it substitute for advice from an appropriately qualified medical professional. No warranty of safety should result from its use.

The screening system in no way guarantees against injury or death. No responsibility or liability whatsoever can be accepted by Metamorphica Martial Arts Pty Ltd for any loss, damage or injury that may arise from any person acting on any statement or information contained in this tool.

Screening Questions

1. Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?

2. Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?

3. Do you ever feel faint, dizzy or lose balance during physical activity/exercise?

4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?

5. If you have diabetes (type l or type ll) have you had trouble controlling your blood sugar (glucose) in the last 3 months?

6. Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?

7. Do you have any other conditions that may require special consideration for you to exercise?

Screening Outcomes

IF YOU ANSWERED YES:

to ANY of the 7 questions, please seek guidance from an appropriate allied health professional or medical practitioner prior to undertaking exercise.

ALL NO ANSWERS:

IF YOU ANSWERED 'NO' to all of the 7 questions, and you have no other concerns about your health, you may proceed to undertake light-moderate intensity physical activity/exercise. You meet the criteria to proceed

I Meet the Criteria to Proceed*

Yes, I answered 'NO' to all 7 questionsNo, I answered 'YES' to at least one question and acknowledge I need to supply written medical clearance before starting training

I agree to the use of an electronic signature to confirm I agree to terms and conditions of training at Metamorphica Martial Arts Pty Ltd. Signature:

On submission of this form you will be booked in to start your free trial on the date you selected and automatically given 7 days free credit!

Metamorphica MMA Trial Form