Personal details

First name

Last name

Birthday

Day

Month

Year

Address

Phone

Email

Next of kin

Name

Phone

Please complete the questions below.

Kindly note: if you answer ‘Yes’ to any of the following questions, you may be asked to provide consent from your doctor before taking part in a class with IndulgDance Fitness.

Has a doctor ever said that you have a heart condition and recommended only medically supervised activity?

Yes

No

Do you have chest pain brought on by physical activity?

Yes

No

Have you developed chest pain in the last month?

Yes

No

Do you lose consciousness or fall over as a result of dizziness?

Yes

No

Do you have a bone or joint problem that could be aggravated by physical activity?

Yes

No

Has a doctor ever recommended medication for your blood pressure or a heart condition?

Yes

No

Are you pregnant or have had a baby in the last 6 months?

Yes

No

Do you suffer from photosensitive epilepsy?

Yes

No

Are you taking any blood thinning medication?

Yes

No

Are you aware through your own experience or from doctors advice of any other reason why you should not exercise without medical supervision?

Yes

No

If you selected any of the above, please provide details:

A little bit about yourself and your goals...

What are your personal fitness or wellbeing goals?

Have you done any similar exercises before?

What are you hoping to gain from joining this class?

And just one last question…

Informed consent:

I realise that my body’s reaction to exercise is not totally predictable. Should I develop a condition that affects my ability to exercise, I will inform my instructor immediately and stop exercising if necessary.

I always take full responsibility for monitoring my own physical condition.

Signature

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