STRICTLY PRIVATE & CONFIDENTIAL
Name
Name
*
First
Last
Date of Birth
Date of Birth
*
/
DD
/
MM
YYYY
Email
*
Phone
*
Emergency Contact's Name
Emergency Contact's Name
*
First
Last
Emergency Contact's Telephone Number
*
Have you ever suffered from epilepsy/seizures?
*
Have you ever suffered from epilepsy/seizures?
Yes
No
Are you pregnant?
*
Are you pregnant?
No
Yes (1-3 months)
Yes (4-6 months)
Yes (7-9 months)
Have you ever suffered from heart trouble?
*
Have you ever suffered from heart trouble?
Yes
No
Are you presently taking any form of medication?
*
Are you presently taking any form of medication?
Yes
No
Do you suffer from chest pains?
*
Do you suffer from chest pains?
Yes
No
Do you ever have spells of dizziness or feel faint?
*
Do you ever have spells of dizziness or feel faint?
Yes
No
Have you ever had a high or low blood pressure and/or high cholesterol?
*
Have you ever had a high or low blood pressure and/or high cholesterol?
Yes
No
Do you have asthma/chronic bronchitis or any other chest ailments?
*
Do you have asthma/chronic bronchitis or any other chest ailments?
Yes
No
Do you suffer from back pain or any other orthopaedic problem?
*
Do you suffer from back pain or any other orthopaedic problem?
Yes
No
Do you suffer from severe headaches or migraines?
*
Do you suffer from severe headaches or migraines?
Yes
No
Are you recovering from a recent illness/injury or surgery?
*
Are you recovering from a recent illness/injury or surgery?
Yes
No
Have you any medical condition or disability that we should be made aware of?
*
Have you any medical condition or disability that we should be made aware of?
Yes
No
Please give details:
Is there any history of heart disease in your immediate family (before the age of 55)?
*
Is there any history of heart disease in your immediate family (before the age of 55)?
Yes
No
Please note, if you have answered yes to any questions noted 1 - 13, you're advised to seek medical advice and your GPS approval before taking part in this class.
I have been informed both verbally and in writing that if I answer yes to any of the above questions, 1 - 13 of the questionnaire, I should seek medical advice and approval before commencing Zumba or Clubbercise® class. If I wish to continue without such advice, I do so entirely at my own risk. I confirm that I have read fully, understand, and answered honestly. I understand that neither the instructor or Clubbercise® Limited can be held responsible for any injuries or ill health of any kind arising from participation in this class.
*
Draw
or
Type
I understand this is a legal representation of my signature.
Clear
Full Name
I understand this is a legal representation of my signature.