Community Active & Wellbeing CIC – Customer Health Declaration Form

Community Active & Wellbeing CIC – New Customer Health Declaration Form

Please complete this before your first session.This helps us adapt sessions safely and appropriately.
This form is designed to support you in taking charge of your health and wellbeing. Regular physical activity has many proven benefits, and completing this health declaration is a sensible first step if you are planning to increase your activity levels.

For most people, taking part in exercise is safe and should not cause any problems.

Community Active & Wellbeing CIC uses this form to identify the small number of individuals for whom certain types of physical activity may be unsuitable, or who may benefit from seeking medical advice before taking part, to ensure the most appropriate and safe option is chosen.

Please answer the questions as accurately as you can. If you are unsure about anything, use your best judgement and speak to a member of our team before your session.

1) Customer Details
Name*

PrefixFirst NameLast Name
Date of Birth*

DayMonthYear
Date
Address*
Postcode*
Contact Telephone Number*
Please enter a valid phone number.Format: 00000 000000.
Yes, I consent to being added to the relevant WhatsApp groupNo, I do not wish to be added
Email*
example@example.com
Yes, I would like to receive email updates from Community Active & Wellbeing CICNo, I do not want to receive email updates
You can withdraw your consent from amrketing and service updates at any time by contacting us at info@communityactiveandwellbeing.org

2) Emergency Contact(s) / Next of Kin
Emergency Contact Name*

First NameLast Name
Relationship*
Relationship to you. e.g. Partner, Brother, Friend
Emergency Contact Number*
Please enter a valid phone number.Format: 00000 000000.
Emergency Contact Name (Additional)

First NameLast Name
Relationship
Relationship to you. e.g. Partner, Brother, Friend
Emergency Contact Number
Please enter a valid phone number.Format: 00000 000000.

5.) Injuries / Pain / Limitations
YesNo
If you answered yes - (please provide details)

7) Additional Support / Accessibility
Lower impact optionsSeated exercise optionsExtra balance supportHearing/communication supportVisual supportLearning / cognitive supportOther (please specify)No
If you answered other - (please provide details)

8) Lifestyle, Exercise & Activity Background
Not activeLightly active (walking only)Moderately active (exercise 1–2x/week)Active (3+ times/week)
Smoker (Current)VaperEx-SmokerNever smokedPrefer not to say

9) Terms & Conditions
Consent & Declaration

Please read carefully before signing. By taking part in any physical activity session delivered by Community Active & Wellbeing CIC
I consent and declare to the following statements:*
- I confirm the information provided is accurate to the best of my knowledge.
- I agree to inform Community Active & Wellbeing CIC of any changes in my medication and the results of any future investigations, treatment or health and will postpone attendance onto any programme or session if I feel unwell or have a temporary illness.
- I understand that I am responsible for monitoring my own responses during exercise and will inform the instructor of any new or unusual symptoms. I must exercise within my own limits and inform the instructor if I feel unwell.
Waiver, Assumption of Risk & Liability

Please read carefully before signing. By taking part in any physical activity session delivered by Community Active & Wellbeing CIC
I understand and agree to the following statements:*
- Voluntary Participation - I am choosing to participate voluntarily and confirm that I feel well enough to take part. I understand I should seek medical advice if I am unsure whether exercise is suitable for me
- Assumption of Risk - I understand that physical activity involves inherent risks. These risks may include (but are not limited to) muscle soreness, strains, sprains, falls, injury, worsening of existing medical conditions, illness, and in rare cases, serious injury or death.
- Personal Responsibility - I agree to exercise within my own limits and ability and to follow the instructor’s guidance and safety instructions at all times. I will stop exercising immediately and inform the instructor if I feel unwell or develop symptoms such as chest pain, dizziness, faintness, or unusual shortness of breath.
- Medical Clearance Where Required - If my health declaration indicates any concerns, I understand I may be required to obtain guidance/consent from my GP or healthcare professional before participating, or my activity may need to be adapted for safety.
- Limitation of Liability - To the fullest extent permitted by law, I accept that Community Active & Wellbeing CIC, its directors, staff, volunteers and instructors will not be held liable for any injury, illness, loss, or damage arising from my participation, except where caused by proven negligence or breach of duty that cannot legally be excluded.
- I have read and understood both the consent & declaration and the Waiver & Assumption of Risk & Liability and agree to these terms
Name*

PrefixFirst NameLast Name
E-signature*

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Date*

DayMonthYear
Date
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Community Active & Wellbeing CIC – New Customer Health Declaration Form

1) Customer Details

2) Emergency Contact(s) / Next of Kin

3) Health Conditions

4) Symptoms / Safety Screening (Red Flags)

5.) Injuries / Pain / Limitations

6.) Medications (Tick all that apply)

7) Additional Support / Accessibility

8) Lifestyle, Exercise & Activity Background

9) Terms & Conditions

Consent & Declaration

Waiver, Assumption of Risk & Liability