SECTION 1. PERSONAL DETAILS
ALL information contained within this form will be kept STRICTLY confidential. YOU ARE REQUIRED TO ANSWER ALL QUESTIONS HONESTLY AND TO THE BEST OF YOUR ABILITY. IF YOU ARE UNSURE OF ANYTHING, PLEASE CONTACT A SYDNEY SURVIVORS REPRESENTATIVE
Name *
Name
Gender *
Date of Birth *
Date of Birth
Address *
Address
Mobile Phone
Mobile Phone
How did you hear about Sydney Survivors *
SECTION 2. EMERGENCY CONTACT DETAILS
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Phone *
Emergency Contact Phone
SECTION 3. Pre-Exercise screening
Do you have a FAMILY HISTORY of heart disease, stroke, raised cholesterol or sudden death?
Do you have Low or High Blood Pressure *
Have you ever been diagnosed with a heart condition, murmur or suffered a stroke? *
Do you have a history of High Cholesterol? *
Do you have any respiratory conditions (Including asthma) *
Have you, or do you suffer from shortness of breath? *
Do you suffer from ANY allergies? *
Have you, or are you currently suffering from any of the following conditions?
Please select if YES
Details should include nature/type of condition, year of diagnosis, current condition and any other pertinent information
Section 4. Are you, or have you recently had or done any of the following?
Are you a MALE over 35 years of age and NOT used to regular exercise? *
Are you a FEMALE over 45 years of age and NOT used to regular exercise? *
Are you taking prescription medication? *
Are you pregnant or have you given birth in the last 6 weeks? *
Have you been hospitalised recently? *
Within the past 12 months
Do you suffer from any infections or infectious diseases? *
IF YOU HAVE ANSWERED YES TO ANY OF THE QUESTIONS IN SECTIONS 3 & 4, OR IF YOU ARE ''NOT SURE' - WE STRONGLY RECOMMEND THAT YOU CONSULT WITH YOUR DOCTOR PRIOR TO COMMENCING AN EXERCISE PROGRAM
SECTION 5. INJURIES & OTHER INFORMATION
Have you ever had, or do you have any pain or major injuries in the following areas which may be reason to modify your exercise program?
Have you had any major surgery? *
Are there any other conditions NOT mentioned above which may be a reason to modify your exercise program? *
1 = very poor; 5 = average, 10 = excellent
Section 6 - TERMS & CONDITIONS
During training with Sydney Survivors, every effort will be made to ensure the safety of all participants. However, as with any exercise program, there are certain risks, including increased heart stress and the chance of musculoskeletal injuries.
I acknowledge that I am aware of the TERMS & CONDITIONS outlined for training with Sydney Survivors *
Section 7 - INDEMNITY CLAUSE
By selecting the following buttons, you MUST fully understand the terms and conditions of participating in training with Sydney Survivors, including the Indemnity Clause as listed below. By clicking these buttons I agree to fully abide by, and accept these conditions for the period of time in which I participate in the transformation - and understand that if my circumstances change whatsoever during the course of me training with Sydney Survivors, that I will inform Sydney Survivors management immediately.
By selecting the following buttons, I agree to the following: *