Name
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First Name
Last Name
Email Address
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone number
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Emergency contact number
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Delivery date
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MM
DD
YYYY
How old is your baby or babies
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GP
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6/8 Week check up and outcome
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How did you hear about Keep Mums Fit?
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Please tick all that apply
Type of delivery
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Feeding
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Pain
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Do you currently suffer with any aches and pains?
If yes please comment below
If you have ticked any of the above please give further details
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Do any of the following apply to you please Tick
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If you have ticked any of the above please give further details
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List any Medications you have been prescribed
Tick the type of exercise you did regularly prior to becoming pregnant
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What exercise, if any would you like to return to?
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Your main fitness and activity goal?
Informed consent and Waiver
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Informed consent and 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 / 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 I have read and agree to the terms and conditions available in the footer of this webpage
