PLEASE SELECT THE CLASS(ES) YOU WOULD LIKE TO ATTEND: *

Monday - Strength

Tuesday - Yoga/Pilates

Both classes - Monday & Tuesday

Please enter your name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mobile and/or landline number(s) *

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Please enter your emergency contact's name *

First Name

Last Name

Emergency contact's Mobile and/or landline number(s) *

(###)

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Please read the questions carefully and answer them honestly by ticking YES or NO. Please feel free to discuss any issues surrounding them with your instructor.

Has your doctor ever said that you have a heart condition, and that you should only do physical activity recommended by a doctor?

YES

NO

*

Do you feel pain in your chest when you do any physical activity?

YES

NO

*

In the past month, have you had any chest pain when you were not doing physical activity?

YES

NO

*

Do you lose your balance because of dizziness, or do you ever lose consciousness?

YES

NO

*

Do you have a bone or joint problem that could be made worse by a change in your physical activity level?

YES

NO

*

Is your doctor currently prescribing any medication for your blood pressure or a heart condition?

YES

NO

*

Have you had surgery recently?

YES

NO

*

Do you have any injuries, joint problems, illnesses/ disabilities?

YES

NO

If you have answered yes to any questions, we require you to discuss it with your doctor before you start to exercise. Please ask your doctor for advice about any activities that you may or may or not be able to participate in. If you have answered no to all questions, you can start to become more physically active. The safest way is to start slowly and build up gradually. Your instructor will be able to give you advice on how to begin. *

Do you have a carer that will be accompanying you?

YES

NO

*

Do you require transport in order to attend the session(s)? If ticked yes, someone from NFG will be in contact with you shortly.

YES

NO

Where did you hear about this event? *

Facebook

YES

NO

*

Email

YES

NO

*

Word of mouth

YES

NO

PERMISSIONS *

I have understood and answered all of the above questions honestly. I understand that I should not exercise if I feel unwell and I will seek medical assistance. I understand that if my health changes I will inform my instructor and complete an up-to-date health screening questionnaire. I understand that there is a risk of injury as with any program of activity. I confirm that I am fit and well and I am taking part in this class of my own free will. I agree to follow the class instructions, issued by the instructor. Where I have a medical condition, discomfort or injury which may be affected by physical activity or this occurs at any time when participating in or after a class, I am responsible for checking with my doctor to ensure I am able to continue to participate. I have answered the health screening questionnaire honestly, I have sought medical advice where necessary and I accept full responsibility for my own health. I understand that to be eligible for the fitness classes I live within the NFG catchment area (check first the “About Us” section on NFG’s website whereby you can view map of the catchment area). I agree to the Northern Fells Group collecting and storing my personal data for purposes relating to my health in relation to the delivery of exercise classes, and to keep me updated about the group exercise classes. Further details can be found on the 'Privacy Policy' on the website (at the bottom of the “Home Page”). Unless otherwise indicated below on this form, I agree to be photographed by the organisers of the event or activities on the day with photos potentially being used for NFG publicity. (If you DO NOT wish your photograph to be taken, you still need to check the agree box to attend, but you MUST also check the final boxes under 'Photography').

I agree

Name of Doctor *

First Name

Last Name

Telephone number of Doctor *

(###)

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PHOTOGRAPHY

When consent is NOT GIVEN please tick the following sentence:

I do not consent to being photographed by the organisers of the event or activities on the day

If you do not wish to be photographed, you confirm that you will make this fact known to the photographer and the organisers on the day.