Core Connections Screening Form

Thank you for booking onto the Core connections workshop – Both Sarah and I are looking forward to seeing you all.

The session will start at 14.30pm please arrive no later than 14.15pm to register.

Sarah will be on hand to individually assess abdominal tone and give preliminary advice before the session starts.

Wear comfortable clothes that you can move in as I will be taking the exercise session in the second half.

This will be the first time at the venue Kate Campbell fitness - we are located Below the Miller and Carter steak house pub on Ecclesall Road South. Parking is the bottom car park.

Babies are welcome, mats and baby chairs available. Unfortunately we cannot accommodate pre-schoolers.

The information collected in this form will be used only for the purpose of designing an appropriate fitness program for you and will not be disclosed to any third party without your consent.

We reserve the right to request a doctor’s clearance before allowing you to receive personal training with Kate Campbell Fitness.

Please fill out the form as thoroughly as possible.

Any questions please do not hesitate to contact Kate Campbell Fitness info@katecampbellfitness.com

Name

First Name

Last Name

Date of Birth

YYYY

Email Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone number

Emergency Contact Name

Emergency Contact Number

Date baby born/due date

YYYY

What type of delivery did you have?

Do you feel you have recovered? Please comment

Have you now or in the past suffered any pelvic floor or urinary problems? Please comment

Are you undergoing any treatment from a physiotherapist currently?

Did you take you take part in regular exercise prior to becoming pregnant? Please comment

What is the main reason for attending the workshop?

What are your health and fitness aims and goals?

How did you hear about the classes/course?

Waiver

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 safe and minimise the risks whist 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 will inform Kate or the KMF team instructors 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. 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.

I agree

Terms and Conditions

I have read and agreed to the terms and conditions (available in the page footer)

Yes