Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone Number (Mobile) *

(###)

###

####

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone Number *

(###)

###

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How many classes would you like to attend a week? *

One

Two

Please indicate if you suffer from any of the following medical conditions?

Please seek medical clearance prior to commencing an exercise class at The White Barn if you suffer from any of these conditions.

Anaemia

Arthritis

Asthma

Back pain

Bronchitis

Cancer

Concussion

Diabetes (Type I or II)

Emphysema

Epilepsy

Eye/Vision problems

Gout

Hearing loss

Heart condition

High cholesterol

High or low BP

Infectious diseases

Kidney disease

Mental illness

Neck pain

Muscle or joint injuries

Stroke

Thyroid problems

Other

Please confirm: *

I have read this form and answered all questions honestly and to the best of my ability.

I understand the importance of health and safety in a gym studio environment.

I understand that it is my responsibility to fully disclose all information in regards to my personal health and seek medical clearance where required.

At the onset of any unusual feeling (e.g. chest pain, nausea, difficult breathing, light headedness) I will stop exercising and immediately report the problem to my trainer.

I have read and understand this agreement. I understand the risks involved in undertaking group training classes and take full responsibility for these risks.

Date *

MM

DD

YYYY