Casual Visit - Health Mates Fitness Centre

Full Name *

DOB (DD/MM/YY) *

Age *

Email *

Mobile *

RWC Membership #

Have You Been To A Fitness Centre Before? *

YesNo

If Yes, How Long Ago?

What are your top two goals you want to achieve by coming to the gym? *

How Did You Hear About Us? *

GoogleSocial MediaRWC JournalI Was A Previous MemberIn Club AdvertisingGym MemberMedical ReferralOther (Please Specify Below)

If you selected 'Other' Above, Please specify

Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke? *

YesNo

Do you ever experience unexplained pains in your chest at rest or during physical activity / exercise? *

YesNo

Do you ever feel faint or have spells of dizziness during physical activity / exercise that causes you to lose balance? *

YesNo

Have you had an asthma attack requiring immediate medical attention at any time over the last 12mths? *

YesNo

If you have Diabetes (type 1 or type 2) have you had trouble controlling your blood glucose in the last 3mths? *

YesNo

Have you been told that you have high blood pressure? *

YesNo

Have you any other medical conditions that may make it dangerous for you to participate in physical activity / exercise? *

YesNo

Waiver *

I acknowledge and agree that: WARNING: When engaging in fitness programs and group exercise classes accidents can happen which may result in my injury, or my death. I declare that I have voluntarily read and understood this Warning, Exclusion of Liability and Release and Indemnity and accept and assume the risk of injury from participating in fitness programs resistance training, cardiovascular training and group exercise classes including Yoga and Pilates, as well as participating in any other activity carried out by Health Mates or by it’s registered fitness professionals. EXCLUSION OF LIABILITY Except to the extent that terms are implied into a contract for sale of goods and services by the Trade Practices Acts 1974 (Cth) or other legislation, and cannot by contract be excluded, I agree that in consideration of being allowed to participate in fitness activities of Health Mates that Health Mates, and it’s directors, fitness professionals, employees, agents or contractors are absolved from all liability however arising from any injury or damage, however caused (whether fatal or otherwise) due to any act of negligence to the fullest extent permitted by law (other than gross negligence) breach of duty, default and/or omission on the part of Health Mates. RELEASE AND INDEMNITY In consideration of Health Mates providing me with a membership (paid or non-paid) which entitles me to engage in fitness activities of Health Mates, I; 1) release and forever discharge Health Mates from all actions, suits, proceedings, claims, demands, losses, damages, penalties, fines, costs and expenses, arising from or in connection with my involvement in fitness activities of Health Mates; and 2) indemnify Health Mares to the extent permitted under the Trade Practices Acts 1974 (Cth)or otherwise by law in respect of any actions, suits, proceedings, claims, demands, losses, damages, penalties, fines, costs and expenses, arising as a result of or in connection with my involvement in fitness activities of Health Mates whether caused or contributed to directly or indirectly, by any act of negligence to the fullest extent permitted by law (other than gross negligence) breach of duty, default and/or omission on the part of Health Mates. 3) I agree that photographs and video footage may be taken of me participating in exercise/classes/Personal Training/Bootcamp without compensation, and consent to the use of these photographs and/or video footage for the advertising of Health Mates. FITNESS TO PARTICIPATE I declare that I am medically and physically fit and free from impairment, and able to participate in fitness activities. I have undertaken or will undertake all necessary medical and/or fitness assessments and examinations. I agree to obtain medical clearances if requested by Health Mates prior to commencing exercise. I also agree to inform Health Mates immediately should any of the information on this form change. I HAVE READ, UNDERSTOOD, AGREE WITH AND ACKNOWLEGE BY SIGNING THE ABOVE WARNING, EXCLUSION OF LIABILTY AND RELEASE AND INDEMINITY, AND I ASSUME WITH FULL KNOWLEGE THE DANGERS IN MY PARTICIPATING IN FITNESS ACTIVITIES AND DO SO AT MY OWN RISK.YesNo

Date *

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