In Balance Fitness Lakes Entrance- casual entry.
Please be at the front door to gain access when completing this form.
Full name
*
First Name
Last Name
Email
*
example@example.com
Date of Birth
*
/
Day
/
Month
Year
Date
Phone Number
*
Address
*
Street Address
Street Address Line 2
Suburb
State
Postcode
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
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EXERCISE READINESS (Par-Q)
Please read the questions carefully and answer each one honestly: check YES or NO.
Par-Q
*
Yes
No
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
n the past month, have you had chest pain when you were not doing physical activity?
Do you lose balance because of dizziness or do you ever lose consciousness?
Do you have bone or joint problem (for example, back, knee, or hip) that could be worsen by a change in your physical activity?
Is your doctor currently prescribing drugs (for example water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?
Further details on above conditions (or on a condition not mentioned above)
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ENTRY CONDITIONS
Please read and check each of the following conditions.
For security purposes, In Balance Fitness uses video surveillance equipment to monitor the club - 24 hours/7 days. By signing this Agreement you acknowledge that you will be subject to video and audio surveillance and recording. Video surveillance is limited to the floor area only, and is not within the walls of the bathrooms or assessment rooms.
*
Acknowledged.
If you cause damage to the club or any equipment you are liable to In Balance Fitness for its cost of repair or replacement *
*
Acknowledged.
In Balance Fitness reserves the right to terminate the passes of anyone who allows access to any additional person with their casual access. A breach of these conditions will incur a $150 fine
*
Acknowledged.
Any charges associated with pressing duress buttons –for any reason, other than an emergency will be covered by myself
*
Acknowledged.
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Signature
*
My Products
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( X )
Casual Session
Please call 0422 058 330 and be at the door at Lakes Entrance, to be given access when payment is complete. (you will receive a thank you message with these details upon completion of payment)
$
14.95
AUD
Quantity
1
Submit
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