Fit-N-Active Boot Camp Health and Fitness For Men, Ladies, Kids and Corporate

.....Sign Up

Name*
Date of Birth:
Day*
Month*
Year*
Gender*	Male Female
Street*
Suburb*
State*
Post Code*
Phone (H)
Phone (M)
Phone (W)
Email*
In case of emergency, whom may we contact?
Contact Name*
Contact Relationship*
Contact Phone (H)
Contact Phone (M)
Contact Phone (W)
Name of other people who may also be interested in joining the Fit n Active Bootcamp
Name
Phone
Name
Phone
Medical History (please tick all that apply)
	Any Heart Conditions
	Liver or Kidney Condition
	High /Low Blood Pressure
	Stomach or Duodenal Ulcers
	Palpitations or Pains in the Chest
	Arthritis, Asthma, Cramps, Muscular Pain
	Heart Murmur
	Do you Smoke
	Have you been hospitalized recently ?
	Are you dieting or fasting?
	Are you pregnant?
	Rheumatic Fever, Dizziness or Fainting
	Raised Cholesterol / Triglycerides
	Any pain or major injuries to the Neck, Back, Knees, Ankles
	Gout, Stroke, Diabetes
	Do you suffer from any injuries (bone or muscle disabilities)?
	Epilepsy, Hernia, Glandular Fever
	Other?
Do you have medical clearance to participate in the Fit n Active Bootcamp?*
	Yes No
How did you hear about Fit n Active?*

If other, please explain:*
Main Occupation
Have you ever worked with a personal trainer before?*
	Yes No
If yes, what did you like most about their training methods?

What did you dislike most about their training methods?

Do you participate in a regular exercise program at this time?*
	Yes No
If yes, briefly describe:*
Do you follow or have you recently followed any specific dietary intake plan, and in general how do you feel about your nutritional habits?

What are your health and fitness objectives?
	Fat Loss
	Strength
	Muscle Tone
	General Fitness
	Flexibility/Posture
	Sport-Specific
	Nutrition
	Stress Management
	Increase Stamina
	Increase Energy Levels
	Rehabilitate part of my body
Other important goals not listed:
When would you like to achieve these goals by?
Which time slot will you be participating in?
	9:30am-10:30am (Monday, Tuesday and Thursday)
	6:30pm-7:30pm (Monday, Tuesday and Thursday)
	7:30pm-8:30pm (Monday, Tuesday and Thursday)
Thank you for completing the questionnaire. Agreement of participating in the Fit n Active Bootcamp (Legal Document) Please Download and Read the Fit n Active Terms and Conditions Privacy Statement The information you give on the health screen form is collected for the purpose of creation of a record on Fit n Active database, attending to administrative matters and corresponding with you. No personal information collected from you will be passed on to any other organization without your consent. If you choose not to complete all the questions on this form it may not be possible for Fit n Active to allow you to participate in this activity. You have the right to access personal information that Fit n Active holds about you subject to any exceptions in the relevant legislation. If you wish to seek access to your personal information, please contact Fit n Active on 0415 550 941.
I acknowledge that I have read and fully understand the above agreement and also the terms and conditions outlined in the Fit n Active disclaimer.

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