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
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First Name
Last Name
Emergency Contact Phone Number
*
Employment activity
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Pre-Maternity Leave: 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? When will you return to work?
GP Surgery
Delivery Date
*
MM
DD
YYYY
Type of Delivery
*
How are you feeding?
*
Tell me about your birth experience
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How was labour and birth
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
Pain
*
Do you currently suffer with any aches and pains?
If yes please comment below
If you have ticked any of the above please give further details
Do any of the following apply to you please Tick
*
If you have ticked any of the above please give further details
*
List any Medications you have been prescribed
Tick the type of exercise you would like to get back to
*
If you have ticked other what exercise, would you like to return to?
*
If weight loss is important to you, tell me about your weight or dieting history
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What would you like to know more about?
Do you know of any other reason why you should not take part in a physical activity programme?
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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 programme, 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 programme, there is a risk of injury. I agree to participate in the exercise programme 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)
