Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Do you have a heart condition and/or have you been recommended for medically supervised activity? *

Yes

No

Do you have chest pain brought on by physical activity? *

Yes

No

Do you suffer from dizziness or fainting? *

Yes

No

Do you have a joint problem that could be aggravated by physical activity? *

Yes

No

Are you a diabetic? *

Yes

No

Has a doctor ever recommended medication for your blood pressure or a heart condition? *

Yes

No

Do you suffer from breathlessness after slight exertion? *

Yes

No

Are you over 65 and unaccustomed to regular physical exercise? *

Yes

No

Do you have a family history of heart disease in parents or siblings below the age of 65? *

Yes

No

Are you currently pregnant or have you had a baby in the last six months? *

Yes

No

Is there any other reason why you should not partake in regular physical activity? *

Yes

No

Do you have high/raised blood pressure (hypertension)? *

Yes

No

Do you suffer from Epilepsy? *

Yes

No

Do you exercise regularly? *

Yes

No

I recognise, and agree, that the instructor is not able to provide me with medical advice with regard to my medical fitness and that the above information is used only as a guideline to the limitations of my ability to exercise. I understand, and agree, that I partake in this exercise at my own risk. *

Yes, I agree

I agree that any photographic or film material in which my image is shown can be used for promotional purposes by Gym in the Park *

Yes, I agree