Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Next of Kin

First Name

Last Name

1 - Have you ever been told by your doctor that you have a heart condition and you should only do physical activity recommended by your doctor? *

Yes

No

2 - When taking part in physical activity do you feel pain in your chest? *

Yes

No

3 - Have you had any pain in your chest in the last month regardless of what type of activity? *

Yes

No

4 - Have you ever had or have you a bone or joint problem that could be made worse by physical activity? *

Yes

No

5 - Do you ever feel dizzy or lose consciousness? *

Yes

No

6 - Is there any reason that you know of that would be why you should not do physical activity? *

Yes

No

7 - Do you take any medications, either prescription or non-prescription, on a regular basis? *

Yes

No

8 - Is there any history of cardiovascular or pulmonary conditions in your family? *

Yes

No

9 - Have you had recent surgery? *

Yes

No

10 - Are you pregnant or under 12 weeks post-natal? *

Yes

No

11 - Are you presenting any symptoms of COVID-19? *

Yes

No

12 - Do you have asthma or exercise induced asthma? *

Yes

No

13 - Do you have low blood sugar levels? *

Yes

No

14 - Do you have diabetes? *

Yes

No

15 - Do you agree to the taking and posting of group photos for social media purposes? *

Yes

No

I accept the waiver statement below: *

All of the above information is true to my knowledge and I bond to inform Leanne Rive whenever there is change in my health status. I participate at my own risk. I understand that like with any sport there are risks such as: increased heart rate and musculoskeletal injuries. I warrant that I am physically well to take part in Kettlercise class / Rive Pilates Class / or a personal training session with Leanne Rive (whichever is applicable) I hereby waive, release and forever discharge Leanne Rive Personal Training from all liabilities for injuries on my participation in Kettlercise. I have read and understand the advice given above. I am aware that all the above information will remain confidential.

Yes