First Name
Surname
Street
Suburb
City
Home Phone
Mobile
Email
Date of Birth dd/mm/yyyy
EMERGENCY CONTACT
First Name / Surname
Relationship to you
Phone
PRE-EXERCISE QUESTIONARE
Do you suffer from any of the following?
Please state
Are you on any Medications?
If yes please list medications
Do you smoke?
Please list any previous injuries which can impact your training
Doctor / GP
I declare the information I have provided is true and correct. I agree to the terms and conditions set out in this agreement
Signature (Type Name)
Date : dd/mm/yyyy
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