Register - Gallanty Fitness

Participants must read and understand fully the importance and relevance of this document. The document is not valid until the participant has signed and returned it to Gallant Fitness. Registration forms sent over the Internet must be signed prior to beginning any class with Gallanty Fitness.

Participant’s Details

Name

Surname

Date of Birth

GenderMaleFemale

Month of Programme

Address

Occupation

Employer

Mobile Number

Emergency Contact Details

Name

Mobile Number

Health Information & Declaration

Do you presently exercise?YesNo

Brief outline of your exercise routine

Any major illnesses or disabilities?

Have you been hospitalised recently?YesNo

Do you suffer from any of the following? (Please tick all that apply)

Heart disease

Heart condition

Back pain

Spinal Injuries

Arthritis

Joint pains

Tightness in Chest

Liver/Kidney Condition

Infections

Chronic Cough

Are you pregnant?

Bladder Weakness?

Asthma

Diabetes

Epilepsy

Hernia

Heart Palpitations

Hi/low Blood Pressure

Rheumatic Fever

Regular Headaches

Muscular pain/cramps

High Cholesterol

Allergies to Grass?

Are there any conditions that may limit your physical activity?

Do you have a family history of Heart Disease?YesNo

Are you Male>35yrs unaccustomed to exercise?YesNo

Are you Female>45yrs unaccustomed to exercise?YesNo

Are you currently on any medication/antibiotics/Anti Depressants?YesNo

Undersigned Participant’s Declaration

I declare that the information given in this form is true and complete to the best of my knowledge. I understand that all participants take part at their own risk and must accept personal liability for any injury, illness or loss. I declare that I consider myself to be in good health and fit to participate in my chosen CARDIO BOX SESSION.

Participants’ Name

Participants’ ID

Participants’ Signature

Today’s Date

Witness’ Name

Witness’ ID

Witness’ Signature

Today’s Date

TERMS & CONDITIONS:

Minimum purchase of 12 sessions. Purchased sessions is valid for two months only from the date of the first class. Payment must be made in full prior to classes. Please see PRICING for payment details. For information on trial classes or other packages not listed above, contact me for a quotation.

IMPORTANT INFORMATION:

Participant’s Details

Emergency Contact Details

Health Information & Declaration

Undersigned Participant’s Declaration

TERMS & CONDITIONS: