Registration 8 Week Challenge
Please complete, sign and email this form to
[email protected] to register your place
Acceptance
•
•
•
•
•
I ______________________ agree
To participate in the 8 Week Challenge from Monday 4th May to Sunday 28th June 2015
To pay all fees in full
Understand that my payment is non-refundable
I am and will continue to be medically and physically fit and able to participate in the
course. I am not and will not be a danger to others or myself. I will immediately notify
Exercise and Energy in writing of any change to my fitness and ability to participate.
Unless I notify Exercise and Energy otherwise, I understand and accept that Exercise and
Energy will continue to rely upon this declaration as evidence of my fitness and ability to
participate.
I have provided the information required attached and signed the form. I warrant
that all information provided is true and correct. I have read, understood, acknowledge
and agree to the above & attached declaration including the warning, exclusion of
liability, release and indemnity.
Signature: _________________________________ Date: ___/___/___
Fitness Testing
Note: Sunday 3rd May & Sunday 28th June at 4pm
Payment Amount (please tick)
8 Week Triple Challenge (early bird registration 1st -12th April)
8 Week Triple Challenge (registration 12th -30th April)
8 Week Starter Challenge (early bird registration 1st -12th April)
8 Week Starter Challenge (registration12th- 30th April)
$198.00
$220.00
$153.00
$170.00
Payment Options
Cash
Cheque (make payable to Exercise and Energy)
EFT (BSB: 951-200 AC: 012 376 016)
Credit Card
Debit Card
Name on Card _______________________________ Expiry Date ___/___
Card No _____/_____/_____/_____
CVV ______
Signature: _________________________________ Date: ___/___/___
Questionnaire & Indemnity
Please complete, sign and return this form before
commencing training with E&E.
Personal
Mr Miss Mrs Ms First Name________________Surname Name______________________
Address___________________________________________________________________
DOB ___/____/____
Age ____
Height _____cm
Weight ___ kg
Email:_______________________________________Phone ________________________
How did you hear about Exercise & Energy?
Friend / Flyer / Newspaper / Facebook
Health Questions
Do you smoke?
Yes / No
Have you ever had asthma, used inhaler medication or been troubled
by shortness of breath?
Yes / No
Do you have diabetes or raised blood sugar levels?
Yes / No
Have you ever had epilepsy, experience fits, seizures, convulsions,
fainting or blackouts?
Yes / No
Have you ever had heart disease, heart murmur or irregular heartbeats?
Yes / No
Do you experience chest pain or angina?
Yes / No
Have you ever been told you have high blood pressure?
Yes / No
Have you ever had an injuries that have led you to see a medical practitioner?
Yes / No
Have you ever suffered from arthritis or any bone or joint problems?
Yes / No
Have you undergone any operations in the last 2 years?
Yes / No
Have you ever had shin splints?
Yes / No
Are you currently receiving treatment for any health conditions?
Yes / No
Do you know of ANY other circumstances regarding your health and fitness that MIGHT
make you unable to carry out any excercises conducted during a fitness session? Yes / No
If Yes please give details ___________________________________________________
Training and Exercise Goals
How many times per week do you exercise? _____________
What is your main goal in attending group training?
Weight Loss
Yes /No
Cardio Fitness
Yes/ No
Muscle Tone
Yes /No
Weight Gain
Strength
Other
Yes / No
Yes/ No
___________
Are you training for a specific occasion? _______________________________________
Participant Consent, Waiver and Release From Liability
I acknowledge that participating inactivities sanctioned by Exercise & Energy involves a risk of
personal injury to me and damage to property belonging to others and me. I knowingly and
voluntarily agree to the terms and conditions outlined in this Waiver and Release from Liability.
In Exchange for being permitted to participate in Exercise & Energy programs, I agree to
the following:
1.
I am in good health , have no physical conditions that affect my ability to participate in
any sanctioned activity conducted by Exercise & Energy and have not been advised
otherwise by a medical practitioner.
2.
I agree that I will immediately advise Exercise & Energy if I observe an unsafe
condition with grounds, facilities or equipment.
3.
I assume all risks associated with my participation including without limitation the risk
of any negligence or recklessness by other participants. I understand that there may be
risks involved which are not known to me or to Exercise & Energy at this time or at the
time of the activities in which I may participate, and agree to assume such
unforeseeable risks.
4.
I agree to indemnify, defend and hold harmless Exercise & Energy and their
employees, agents and volunteers from and against any claims, causes of action,
damage, judgments, liabilities, fees (including legal fees), costs and expenses incurred
by Exercise & Energy as a result of my unlawful actions or failure to act during any
activity.
This waiver is a legally binding agreement and will be construed broadly to provide a release and
waiver to the maximum extent permissible under applicable law. Any provisions found to be
Unenforceable shall not affect validity of enforceability of any other provisions, which may be
Modified by acourt having jurisdiction.
Exercise & Energy with not reimbuse members who are unable to sustain the full quantity of
Programmed fitness sessions. Specific cases with external complications will be looked at case
by case.
I have read this document and I understand that by signing below, I have given up substantial
rights, I have voluntary signed this release, with and duress or undue pressure from Exercise &
Energy.
Name _________________________Signature_____________________Date___/___/___
Parent / Guardian Signature for Minors (Aged between 15-17)
As a parent or guardian of a participant in a sanctioned activity of Exercise & Energy, I
agree to the terms and conditions contained in this agreement, and I assume
responsibility for the actions or inactions of the participant (sign for participant)
Parents/ Guardian________________Signature____________________Date____/___/___
M: 0408 56 34 35
FB: /exerciseandenergy
E: [email protected]
W: www.exerciseandenergy.com