Class Member Record

Name

Address

Email Address

Phone

Stay updated Stay updated Please tick this box if you would not like to receive occasional news and class updates by email

Emergency Contact Name

Emergency Contact Address

Emergency Contact Email Address

Emergency Contact Phone

Has your doctor ever said that you have a heart condition and that you should not do physical activity unless recommended by a doctor? Has your doctor ever said that you have a heart condition and that you should not do physical activity unless recommended by a doctor? Yes No

Do you feel pain in your chest when you do physical activity? Do you feel pain in your chest when you do physical activity? Yes No

In the past month, have you had chest pain when you were not doing physical activity? In the past month, have you had chest pain when you were not doing physical activity? Yes No

Do you lose balance because of dizziness or do you ever lose consciousness? Do you lose balance because of dizziness or do you ever lose consciousness? Yes No

Do you have a bone or joint problem that could be made worse by a change in your physical activity? Do you have a bone or joint problem that could be made worse by a change in your physical activity? Yes No

Is your doctor currently prescribing you drugs (for example water pills) for your blood pressure or heart? Is your doctor currently prescribing you drugs (for example water pills) for your blood pressure or heart? Yes No

Do you know any other reason why you should not do physical activity? Do you know any other reason why you should not do physical activity? Yes No

Please provide further information, including how this may affect your participation in the programme.

Photo/video permissions Photo/video permissions I give permission for photos/video to be taken and used for promotional purposes I don not give permission for photos/video to be taken and used for promotional purposes