Your email address:

Student's Name

First Line Of Address

Post Code

Student's Date Of Birth

Students Age

Phone Number (no spaces)

Emergency Contact Name

Emergency Contact Phone Number

Emergency Contact Relationship (Wife, mum, partner?)

Are you (the student)  on any medication?

Do you suffer from high blood pressure, heart disease, diabetes or epilepsy?

Do you have any joint problems or injuries?

Do you suffer with chest problems (e.g. asthma, bronchitis etc?)

Are you a newcomer to exercise?

Have you any physical problem that may affect your exercise program?

Do you have any Allergies?

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.

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.

I will not hold responsible any Instructors or any fellow members of Genesis Gym for any injury I may sustain.

(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.

(OPTIONAL)  I do wish to receive marketing messages from Genesis Gym.  (Your details will not be sent to any other company)

COVID Health Check.  Are you currently diagnosed with, or believe you may have, COVID-19

Form Completed By (if student is under 18, to be completed by Parent or Guardian):

Date

Referred By

Recommendation