Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of birth *

MM

DD

YYYY

Have you ever had any of the following? *

If yes please provide more detail in the comments box below

None of the below

Heart problems Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

Undergone surgery in the last 12 months

High/low blood pressure

Hay fever

Arthritis

Sports injury now or previously

Muscular aches or pains

On-going treatment from a Physio, Chiropractor or Osteopath

In the past month, have you had any chest pain while you were not doing any physical activity?

Do you lose your balance because of dizziness or do you ever faint or lose consciousness?

Do you have a bone or joint problem that could be made worse by physical activity?

Is your GP currently prescribing medicine for your blood pressure or heart condition?

Do you have Asthma or any other breathing problems? Bring inhaler to session

Do you have diabetes?

Are you on any Medication?

Do you have any allergies?

Informed consent and Waiver *

By ticking these boxes I hereby state that I have read understood and answered honestly the screening questionnaire and that my Parents / Guardian has read and agrees with the informed consent. 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, I will use the equipment safely and ask for support from the team if I am unsure. Alternatives, adaptations and suggestions can be made. 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.

I agree

Parents or Guardians read and agree

Terms and conditions *

By ticking this box I have read and agreed to the terms and conditions (available in the page footer)

Yes