Healthy Connections - Fitzgibbon
Membership sign up
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
If we need to contact you, what is the best time of day to get in touch?
*
7am - 11am
11am - 1pm
1pm - 5pm
Date of birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State
Postcode
Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?
*
No
Yes
Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity / exercise?
*
No
Yes
Do you ever feel faint, dizzy or lose balance during physical activity / exercise?
*
No
Yes
Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?
*
No
Yes
If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months?
*
No
Yes
Do you have any other conditions that may require special consideration for you to exercise?
*
No
Yes
What is the condition that may require special consideration?
Do you have any pre-existing injuries that may impact your ability to exercise?
*
No
Yes
Please describe the pre-existing injury
On average, how many minutes a week of light to moderate intensity physical activity / exercise do you do now?
*
On average, how many minutes a week of high intensity physical activity / exercise do you do now?
*
Contact
What are you hoping to improve by exercising with us?
Balance
Cardiorespiratory fitness
Core conditioning and strength
Flexibility
Strength
Weight
Declaration
I agree to voluntarily participate in exercise sessions at Healthy Connections - Fitzgibbon.
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.
Consent required
*
I have read and understood the declaration above and consent to participate in exercise sessions at Healthy Connections - Fitzgibbon.
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