Date:     Name:

Address:


Age:

Home Phone Number:

Mobile Phone Number:

E-mail:

Occupation:

Current illness/disease/condition: N/A

Current or recurring injury: N/A

Are you taking any medication? No  Yes
Please state:

Back/Knee/Joint Problems?

Pregnant? No  Yes

Have you ever suffered from any of the following problems?

Heart Condition: No  Yes

Low Blood Pressure: No  Yes

Diabetes: No  Yes

Faint/Dizziness: No  Yes

Angina: No  Yes

High Blood Pressure: No  Yes

Epilepsy: No  Yes

Schizophrenia: No  Yes

High Cholesterol: No  Yes

Other (please state):

Do you currently exercise? No  Yes

I herby consent to take part in FITNESS YOGA, FITNESS PILATES ,CARDIO AND CORE and CIRCUIT TRAINING at my own risk. 
If I have any known health problems I will discuss them with Peter Webber. If he offers any reason for not joining in any of these exercise programs I will adhere to his recommendations. I fully understand that the risk of undertaking physical activity may include elevation of heartbeat, abnormal blood pressure response and very rarely, a heart attack or death. I further understand that selection and supervision of exercise is a matter of professional judgement. I understand I can withdraw my consent or discontinue participation in any aspect of the fitness programs at any time without penalty or prejudice towards me.

I have read the statement above and all of my questions are answered to my satisfaction.