HEALTH SCREENING FORM & PARTICIPATION WAIVER- Mumma fitness classes held inside (MAXI FIT fitness club- Hall 2)
Company: MUMMA FITNESS BG EOOD UIC: 208559883 This form only needs to be filled out once, prior to attending your first class.
Full name
*
Име
Mothers Date of birth
*
-
Month
-
Day
Year
Date
Phone number
*
-
Area Code
Phone Number
Email
example@example.com
Which communication method do you prefer?
*
Viber
Whatsapp
Birth details
*
Vaginal birth
Caesarian section birth (surgerical)
Have you experienced any of the following symptoms in the last 3 months?
Excessively heavy period
High blood pressure
Dizziness/ Fainting
Aching or pulling feeling from caesarean scar or pelvic area/ vagina
Mothers medical notes: (recent surgery, medical conditions, prescription medication)
How many pregnancies have you had?
Please Select
1
2
3+
Абонирайте се за имейл бюлетини
Да
Не
Emergency contact- Full name
*
First Name
Last Name
Emergency contact- Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Monday's timetable
Thursday's timetable
Baby's name
*
Baby's date of birth
*
-
Month
-
Day
Year
Date
Fitness level
*
I have not exercised in a long time
I exercise occasionally
I exercise regularly
Why do you want to join the class?
To improve my mental health & make mum friends
To tone my body
To gain strength
To improve my confidence
Do you consent to being in photography & videography, and this content to be used on social media and marketing?
*
Yes- Both me and my baby
Yes- Only me, not my baby
No
Signature
*
Submit form
Submit form
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