Name
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First Name
Last Name
Email Address
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Phone Number
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of birth
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MM
DD
YYYY
Emergency contact number
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Next of kin
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GP
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What motivated you to contact Kate Campbell Fitness
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Exercise - Mobility-Antenatal -Postnatal - weight loss - Nutrition or other (Please state)
Describe your current level of fitness
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What Changes, if any are you interested in making
Why is now a good time to work on achieving your health and fitness goals?
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What has prompted you to want to make the change
Have you ever had any of the following?
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If yes please provide more detail in the comments box below
Please add any comments on the above health questions and list any medications you are currently taking and why they have been prescribed.
Do you know of any other reason why you should not take part in a physical activity programme?
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Informed consent and Waiver
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I hereby state that I have read understood and answered honestly the screening questionnaire.
During the exercise programme, every effort is made to keep the class / session safe and minimise the risks whilst providing an effective session. I am participating of my own free will and I am aware, as with any exercise programme, there is a risk of injury. I agree to participate in the exercise programme described to me by Kate Campbell and the Kate Campbell Fitness Team I understand that in order for the session to remain safe, alternatives and adaptations will be made throughout. The structure, purpose, benefits and risks of the session will be explained throughout the class, and I understand that I may withdraw from the session at any time.
I understand it is my responsibility to inform Kate Campbell fitness staff if any physical / Medical changes occur which may prevent me from exercising safely.
If at any time you feel undue pain or excessive discomfort, Stop the activity and inform instructor.
I understand that from time to time photographs will be taken for advertising and promotion, and i agree to have any pictures of me used in this way.I will not hold KATE CAMPBELL FITNESS or staff liable in any way for injuries or illness that may occur while I am training.
COVID -19
By ticking this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that you may be exposed to or infected by COVID-19 by attending Kate Campbell Fitness and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at Kate Campbell Fitness may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Kate Campbell Fitness employees, volunteers, and programme participants and their families.
I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my attendance at Kate Campbell Fitness. On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless Kate Campbell Fitness employees, Freelance instructors and self-employed personal trainers, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of Kate Campbell Fitness, its employees, Freelance instructors and self-employed personal trainers agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any Kate Campbell Fitness programme.
Terms and conditions
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By ticking this box I have read and agreed to the terms and conditions (available in the page footer)
