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Genesis Gym - Application/Disclaimer Form
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* Indicates required question
Email
*
Your email
Student's Name
*
Your answer
First Line Of Address
*
Your answer
Post Code
*
Your answer
Student's Date Of Birth
*
Your answer
Student's Age
Your answer
Phone Number (no spaces)
Your answer
Emergency Contact Name
*
Your answer
Emergency Contact Phone
*
Your answer
Emergency Contact Relationship (Wife/mum?)
Your answer
Are You (the Student) on any medication?
*
Yes
No
Do you suffer from high blood pressure, heart disease, diabetes or epilepsy?
*
Yes
No
Do you have any joint problems or injuries?
*
Yes
No
Do you suffer with chest problems (e.g. asthma, bronchitis etc?)
*
Yes
No
Are you a newcomer to exercise?
*
Yes
No
Have you any physical problem that may affect your exercise program?
*
Yes
No
If you have answered YES to any of the questions above, please give details here:
Your answer
Whilst every care will be taken to the best of the instructor's ability, it is up to the individual to know their own limitations.
*
Agreed
Required
I understand that taking part in fitness training, Martial Arts activities or general Gym use at Genesis Gym involves an element of risk and I take part in any such activity entirely at my own risk.
*
Agreed
Required
I will not hold responsible any Instructors or any fellow members of Genesis Gym for any injury I may sustain.
*
Agreed
Required
(OPTIONAL) I give consent to the usage of any photographic or video-graphic media taken by Genesis Gym. I confirm that I agree to be recognised and/or identified in photography and/or written material for Genesis Gym.
*
Agreed
Not agreed
Required
(OPTIONAL) I do wish to receive marketing messages from Genesis Gym. (Your details will not be sent to any other company)
*
Agreed
Not agreed
Required
COVID Health Check. Are you currently diagnosed with, or believe you may have, COVID-19
*
Yes
No
COVID Health Check. Do you have any of the following symptoms?
*
High Temperature
A new or continuous cough
Loss or chnage to your sense of taste/smell
New unexplained shortness of breath
None of the above
Required
COVID Health Check. Have you been in contact with a COVID-19 confirmed or suspected case in the previous 14 days?
*
Yes
No
Form Completed By (if student is under 18, to be completed by Parent or Guardian):
*
Your answer
Date
*
Your answer
Referred By:
Your answer
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