GJ Fitness For Mums
Helping improve your pelvic floor, core and more.
Please read the Terms and Conditions located on the website
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
County
Postcode
Emergency Name & Phone Number
*
Name
Tel number
Date of postnatal check if applicable (with youngest child)
-
Day
-
Month
Year
Date
Number and age of children if applicable
What type of delivery did you have?
Vaginal
Elective caesarean section
Emergency caesarean section
Details of postnatal recovery
Medical History (please select all that apply)
Pelvic Girdle Pain
Pelvic floor dysfunction (eg.incontinence or urgency to use the toilet)
Prolapse
Csection wound discomfort
Perennial cut / tear
Lower back pain
Sciatica pain
High / low blood pressure
Diabetes
Joint pain or movement reduction
Unexplained vaginal bleeding
Perinatal mental health illness
Other
If you have ticked any of the above please give details below
Please provide details of any other previous medical history you think may be important for GJ Fitness For Mums to know about to help you on your fitness journey
Exercise frequency
None at all
1-2 times per week
More than 3 times per week
What goals would you like to achieve with GJ Fitness For Mums?
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, please check the boxes below to indicate your consent (please select all that apply)
*
Whatts App
Email
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 from GJ Fitness For Mums
I'd like to join the mailing list
Sometimes during classes, photos and videos are taken to be used on Social Media and marketing channels, please tick here to give your consent If you would like them to be published
*
I consent
I do not consent
Please tick to confirm you have read and understood the Terms and Conditions (located on website)
*
I have read the Terms and Conditions (located on website)
Whilst GJ Fitness For Mums endeavours to ensure the safety of all participants, all exercise comes with some risks, and GJ Fitness For Mums cannot be held responsible for any injury or damages incurred. Should your medical or fitness needs change during your time with GJ Fitness For Mums, it is your responsibility to inform your instructor
*
I understand and accept the above statement
Data Protection: The information you provided in this form will be used for my purposes only and will not be shared with any third party without your prior permission. It will be stored safely on my private computer
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I agree
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