Name *

First Name

Last Name

Name *

First Name

Last Name

1. Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke? *

Yes

No

2. Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise? *

Yes

No

3. Do you ever feel faint, dizzy or lose balance during physical activity/exercise? *

Yes

No

4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months? *

Yes

No

5. If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months? *

Yes

No

6. Are you pregnant? *

Yes

No

7. Do you have any other conditions that may require special consideration for you to exercise? *

If you select yes, please give details below at the base of this form.

Yes

No

8. Frequency (number of sessions per week) *

In active for more than 3 months

2-3 sessions per week

4-5

6+

9. Family history of heart disease? *

A family history of heart disease refers to an event that occurs in relatives including parents, grandparents, uncles and/or aunts before the age of 55 years.

Yes

No

10. Do you smoke cigarettes? *

Yes

No

11. Have you been told that you have high blood pressure? *

Yes

No

12. Are there any conditions that may limit your physical activity ? *

If you selected YES, please give details below.

Yes

No

Participants Declaration *

By submitting this form, I declare that the information given in this form is true and complete to the best of my knowledge. I understand that all participants take part at their own risk and must accept personal liability for any injury, illness or loss. I declare that I consider myself to be in good health and fit to participate in my chosen Athletica program. I hereby represent to Athletica, its management, associated companies, trusts, partnerships and other legal entities, their directors, officers, employees, agents, contractors and affiliates that I am physically capable of and there is no medical reason to prevent me from proceeding with any program run by Athletica without endangering my health. I acknowledge that whilst participating in the Athletica program, my person and my property are at my own risk. I acknowledge that I will not hold Athletica responsible for and Athletica hereby excludes, to the extent permitted by law, all liability for any personal injury or damage {whether direct, indirect, special or consequential} suffered by me while I am participating in Athletica program however that injury, damage or loss is caused, including if it is caused by the negligence of Athletica. I acknowledge that except as provided in this document, Athletica gives no warrantee in respect to the services and equipment it provides. I accept that there are no rain checks, refunds or make up days unless at the discretion of Athletica. I hereby permit Athletica to utilise any images and video of myself for promotional or marketing use of the Athletica program. I hereby release and will indemnify Athletica for any injury or loss suffered by me whilst participating in any Athletica program. I have read, understood and agree to the terms and conditions of Athletica.

Yes