About You

Name:	*
Age:	years *
Address:	*
City:	*
Postcode:	*
Date of Birth:	/ /  *
	DD  /  MM /   YY
Occupation:
Phone:	Home Work Mobile
E-mail:	*
Emergency Contact:	Name Phone
Doctor:	Name Phone
How did you hear about us:

Health Matters

Do you smoke:	YesNo
Are you Pregnant:	YesNo
Have you ever had?	Heart Trouble/Family History	Chest Pains
	High Blood Pressure	Arthritis
	Epilepsy	Diabetes
	Bone or Joint Problems	Back Problems
	Faint or Dizzy Spells	Asthma
	Sporting Injuries	Glandular Fever
	Other
Are you on any medication?
Are you on work cover for injury or illness?

Declaration

ACKNOWLEDGEMENT OF RISKS, INJURY AND OBLIGATIONS

WARNING: THIS IS AN IMPORTANT DOCUMENT, WHICH MAY AFFECT YOUR LEGAL RIGHTS AND OBLIGATIONS. PLEASE READ IT CAREFULLY AND DO NOT SIGN IT UNLESS YOU ARE SATISFIED THAT YOU UNDERSTAND IT. IF YOU HAVE ANY QUESTIONS PLEASE ASK OUR STAFF. Fitness Centre Operators: Chizen Health Club, A.J. McKay I acknowledge that any activity I undertake in this centre now or in the future may be dangerous, and that in participating I am exposed to certain risks. I ACKNOWLEDGE AND UNDERSTAND that whilst participating in such activity: · I may be injured, physically or mentally, or worse. · My personal property may be lost or damaged. · I may cause injury to other persons or damage their property. · Other persons participating in such activity may cause me injury or damage to property. · I may be injured or die or suffer damage to my property as a result of the negligence or breach of contract of the Fitness Centre Operator or their staff or agent. · The conditions and location in which the activity is conducted may vary without warning. My activity at times may be on or off the premises, outdoors or in another location. · There may be no or inadequate facilities for treatment or transport of me if I am injured. · I assume the risk of and responsibility for any injury, death or property damage resulting from my participation in the activity now and in the future. RELEASE AND INDEMNITY TO THE FITNESS CENTRE OWNERS/OPERATORS, STAFF, REPRESENTATIVES AND AGENTS In consideration of the acceptance of my payment for participating in the activity (and except to the extent that the same may be precluded by stature) I AGREE TO RELEASE AND INDEMNIFY CHIZEN HEALTH CLUB OWNER/OPERATORS, THEIR STAFF AND REPRESENTATIVES as follows: · I participate in the activity and any future Fitness Centre activities at my sole risk and responsibility, either on or off the premises, for indoor or outdoor health or fitness activities. · I release, indemnify and hold harmless the Fitness Centre Operators and its staff, representatives and agents from and against all and any actions or claims which may be made by me or on my behalf or by other parties for or in respect of or arising out of any injury, loss, damage or death caused to me or my property. · I ALSO AGREE THAT in the event that I am injured or my property is damaged, I will bring no claim, legal or otherwise against Chizen Health Club Operators in respect of that injury or damage now or in the future. I take full responsibility for my actions and my property while at Chizen Health Club. Before signing this document I have read and understood it and know that it affects my legal rights. This document and its information will be deemed to be valid at this time and at any time in the future. If any medical conditions change, I will inform Chizen Health Club immediately.

If you are under 18 years of age, click here to download a copy of the form and see a staff member with your parent/guardian.

Payment

Read the terms and conditions above carefully and click on the submit button for your payment options Acknowledgement  I have read and agree to these terms.