Medical Questionnaire & Media Consent

Please fill out the following form prior to class participation to help

us understand your physical condition. By signing the form you also agree to photos/videos being taken at times in classes for marketing purposes and to inform the teacher if you do not wish to be included.

First Name

Email Address

Last Name

Date of Birth

Do you confirm that there are no mental or physical reasons that you cannot or should not participate in physical exercise?

Yes

Are you currently suffering from a medical condition, illness, or injury?

Yes

If you answered yes to any question, please elaborate

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete and if anything changes I will inform the teachers as soon as possible. I understand the nature of the classes and confirm that I am in appropriate physical and mental condition to participate. If at any time I have questions, feel unsafe or unwell I will immediately inform you and discontinue further participation in the class. I understand that the teachers cannot be held responsible for any injuries or ill health of any kind arising from participation within this class. I also confirm that it is OK to be included on photos/videos for marketing purposes at times and if I do not want to be included I agree to inform the teacher before the class.

Thanks for submitting!