I Love ME - Participant Questionnaire/Contact
Participants questionnaire

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First Name *
Last Name *
Mobile Phone Number *
Home Phone Number
Email address *
Address
Which class/s are you intending to attending? (PLEASE SELECT ALL LOCATIONS YOU ARE INTERESTED IN) *
Required
How did you hear about us?
Clear selection
Do you feel you need to have a doctors clearance for participating in 'I LOVE ME' fitness activities? *
If Yes, Doctor's Name/details (if known):
Do you have any Heart Problems?
Clear selection
Do you have High Blood Pressure?
Clear selection
Do you have Diabetes?
Clear selection
Do you have Asthma?
Clear selection
Do you have Arthritis?
Clear selection
Do you have Osteoporosis?
Clear selection
What medications are you taking?
Do you have any other Health related problems not listed above? If Yes, Please detail
Privacy Statement:
The personal information you provide to I Love ME will not be shared to other third parties. It will be used to enable you to access and be provided with information about services and benefits available to you as a participant in these classes. You have the right to access and correct any information that is inaccurate. From time to time we use this mail list to send notifications, updates or any changes to classes etc. and never share your details with other third parties.

Voluntary Assumption of risk:
You undertake an activity at your own risk and acknowledge and voluntarily accept that level of risk consequent of that activity.
Disclaimer:
I hereby release Anna Levar, I Love ME, its employers and/or contractors from any claims demands and causes of action arising and/or resulting from my participation in these exercise classes.
By clicking 'submit' you agree to the above and that the above is true and correct.

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