Name
*
First Name
Last Name
Email
*
Phone Number
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth
*
MM
DD
YYYY
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
Employment activity
*
Employment activity
What is your job, and what are your working hours? Do you work from home or commute? How do your work patterns affect your health and fitness activity, if at all?
GP Surgery
Estimated date of birth
*
MM
DD
YYYY
Antenatal History
*
Please Ensure the following information is correct.
If you have any previous or current medical conditions, injury or disabilities you may need to speak to your GP or Physiotherapist before you attend. Do any of the following apply to you?
If you have ticked any of the above please give further details
*
Are you taking any medication, have any other health problems, or have any comments on the above?
Exercise History
*
Please state your main goals, aims or reasons for attending Keep Mums Fit group classes or personal training.
*
How did you hear about Keep Mums Fit
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Internet Search
Google
Facebook
Instagram
Other social media
Recommendation from friend or family member
Midwife
GP
Flyer
Previously Attended
Other
What service motivated you to contact us?
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Pre Pregnancy support
Pregnancy fitness and skills for birth class
Personal Training Face to face
Move Well Massage and therapies
Program design
Online Personal training
other
Do you know of any other reason why you should not take part in a physical activity program?
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Informed consent and Waiver
*
I hereby state that I have read understood and answered honestly the screening questionnaire.
During the exercise program, every effort is made to keep the class / session safe and minimise the risks whilst providing an effective session. I am participating of my own free will and I am aware, as with any exercise program, there is a risk of injury. I agree to participate in the exercise program described to me by Kate Campbell and the Kate Campbell Fitness Team I understand that in order for the session to remain safe, alternatives and adaptations will be made throughout. The structure, purpose, benefits and risks of the session will be explained throughout the class, and I understand that I may withdraw from the session at any time.
I understand it is my responsibility to inform Kate Campbell fitness staff if any physical / Medical changes occur which may prevent me from exercising safely.
If at any time you feel undue pain or excessive discomfort, Stop the activity and inform instructor.
I understand that from time to time photographs will be taken for advertising and promotion, and i agree to have any pictures of me used in this way.I will not hold KATE CAMPBELL FITNESS or staff liable in any way for injuries or illness that may occur while I am training.
Terms and conditions
*
By ticking this box I have read and agreed to the terms and conditions (available in the page footer)
