Wellbeing Workouts Registration

Name *

Postal Address

Email Address *

Home Phone

Mobile Phone

Date of Birth

Height

Weight (optional)

Emergency Contact Name *

Emergency Contact Phone *

Previous Exercise Experience

Why do you want to join the Wellbeing Workouts? *

Which sessions will you be attending each week?Tuesday 6amFriday 6am

Do you have or have you ever suffered from:Low/High Blood PressureChest PainRespiratory Problems/AsthmaAngina/Heart AttackStrokeDiabetesKidney/Liver DiseaseHigh CholesterolIrritable Bowel SyndromeThyroid IssuesDizziness/FaintingPelvic Floor/Bladder WeaknessGlandular FeverMajor SurgeryDislocated JointsBroken BonesHeadachesAnkle/Foot PainShoulder PainWrist/Elbow PainBack/Neck PainHip PainKnee PainBack Trauma/InjuryTingling/numb LimbsArthritisOsteoporitisCancerPneumoniaLow Immunity

Notes on health issues above

Is there any other personal information regarding your health you think is necessary to disclose?

How did you hear about the Wellbeing Workouts ? *—Please choose an option—RadioInternet SearchFacebookWord of MouthWhangarei Parent CentreOther

Did somebody refer you? *YesNo

If yes, who

I acknowledge that I have read, understood & accepted the Wellbeing Workouts Terms & Conditions *YesNo