Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

MM

DD

YYYY

Emergency Contact Name

First Name

Last Name

Do you have any medical conditions that will effect your health or ability to undertake a regular exercise program? *

YES

NO

Are you currently taking any prescribed medication? *

YES

NO

Does your prescribed medication have any known side effects that may effect you during exercise? *

YES

NO

N/A

Have you tested positive to COVID 19 *

If yes, please provide further details below and make a staff member aware before progressing with any scheduled training.

YES

NO

Have you displayed symptoms consistent with COVID 19 in the past 14 days? *

YES

NO

Have you arrived from an international location with in the last 14 days? *

YES

NO

Have you associated with someone that has arrived from an international location with in the last 14 days? *

YES

NO

Have you associated with some that has tested positive for COVID 19 with in the last 14 days? *

YES

NO

Do you have any reason to believe that you may have been exposed to COVIDE 19 or that your presence within the gym or an organised group fitness session may put others at risk? *

YES

NO

What would you like to get from this exercise program?

Improve General Health

Body Fat Reduction

Increase Muscle Mass

Improve Cardiovascular Fitness

Improve General Wellbeing

Social

What is your exercise medium?

Group Fitness in a Class Environment (Large Group)

Group Fitness in a Class Environment (Small Group)

Gym Based Training (solo)

Gym Based Training (with a friend)

Personal Training

Would you find benefit in being about to mix training mediums?

No, I like Gym/Classes Only

Yes, I'd like to participate in combination of gym and classes

Client: The client acknowledges and undertakes to: (A) Accurately complete the medical screening questionnaire to the best of the client’s ability and promptly advise the Fitness Centre of any health changes, concerns or new injuries prior to participating in any training session. (B) Provide the Fitness Centre, upon reasonable request, with written medical clearance from the client’s General Practitioner. *

I understand and AGREE

I understand and DO NOT AGREE

Liability Waiver: The client further acknowledges and agrees that due to the nature of the activity it would be unreasonable for Jaydon Grassi or any of his servants or agents to be in any way responsible for any injury to, or death of the client. The client hereby, to the full extent permitted by law, waives all of his or her legal rights of action against and fully releases Jaydon Grassi or his servants or agents for loss, damages, injury or death howsoever arising out of or in relation to the participation by the client in the activities conducted or organized by Jaydon Grassi or any of his servants or agents including without limitation, liability for any negligent or tortuous act or omission, breach of duty, breach of contract or breach of statutory duty on the part of Jaydon Grassi or any of his servants or agents. *

I Understand and AGREE

I Understand and I DO NOT AGREE

Client Name

First Name

Last Name

Agreement Date

MM

DD

YYYY