Fitness Programme with Emma Jane Taylor

Name

First NameLast Name

Date of birth

Email

Address

Address Line 1

Address Line 2

TownCity

Post Code

Phone Number

Prefix - PUT +44Phone Number

Emergency Contact Name/ Phone No

First NameLast Name

Emergency Number

Prefix - PUT +44Phone Number

Do you have any of the following?

Is there anything else that you would like to share about your health, fitness or wellbeing?

If you answered 'yes' to one or more questions:

Please speak directly to Emma Jane Taylor who requested you return this form. Unless decided otherwise, you may be advised to consult with your doctor by telephone or in person before increasing your physical activity. Tell your doctor what questions you answered '"yes'' to on this form or present this as a copy.

After medical evaluation, seek advice from your doctor as to your suitability for unrestricted physical activity starting off easily and progressiong gradually and also restricted or supervised activity to meet your specific needs, at least on an initial basis

If you answered 'no' to all questions:

If you answered this form accurately, you have given reasonable assurance of your present suitability to take part in physical/gym activity, and that you do so with full responsibility of your health, and also you agree to updating Emma Jane with any changes to your health.

Assumption of risk:

I hereby state that I have read, understood and answered honestly the questions on the Health Questionnaire created for Emma Jane Taylors fitness activities -> Personal Fitness training - Wellbeing programmes including nutrition and weight management courses and any other physical activity organised by Emma Jane Taylor. I also state I wish to participate in activites that may include aerobic exercise, resistance training and stretching. I realise that my participation in these activites involves a risk of injury and even the possibility of death. Furthermore, I hereby confirm that I am voluntarily engaging in an acceptable level of exercise and fully understand the risk involved, and my personal responsibility to taking part.

Terms & conditions:

I agree to take full responsibility for my answers included in this health questionnaire. I will seek further medical advice if it deemed necessary to do so, and will update the team with any changes to my health based on the answers given on my form requestrian by Emma Jane Taylor.

I acknowledge the 24 hour cancellation policy.

I understand this form is received in confidence.

*NOTE
Emma Jane Taylor does not discuss any part of her clients sessions in the public domain and is very sensitive to confidentiality and the importance of this. If you wish to share publicly the work you undertake with Emma Jane Taylor and reviews, please do tag and send a copy to Emma Jane Taylor.

Date

Signature - by signing this form you confirm that you have correctly shared your current health status and that you take full responsibility for your wellbeing.