khadijak gym member reg form

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KhadijaK  Gym Member Registration form - WOMEN
CLIENT INFORMATION AND CONSENT FORM
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*Required
FIRST NAME: *
Your answer
SURNAME: *
Your answer
AGE: *
Your answer
Social Media details: Twitter username
Your answer
Social Media details: Instagram username
Your answer
Social Media details: Facebook username
Your answer
Which time slots do your prefer? *
Select as many as you wish:
Required
D/O/BIRTH (Year, Month, Day): *
eg. 1980/09/25
Your answer
Cell No: *
Your answer
Home No: *
Your answer
Work No: *
Your answer
PHYSICAL ADDRESS:
Your answer
POSTAL ADDRESS:
Your answer
EMAIL: *
Your answer
Emergency 1 TEL: *
Emergency contact details of two other people, state relationship.
Your answer
Emergency 2 TEL:
Emergency contact details of two other people, state relationship.
Your answer
ID NO. OF PERSON RESPONSIBLE FOR FEES:
Your answer
What are the main benefits you want from this exercise program? *
Required
Any other specific goals:
Your answer
What type of exercise were you participating in during the last 5 months?
Your answer
Referral – Where did you hear about us? *
Choose as many as you wish
Photographs of participants may be used for marketing, if you do not want to be photographed please state here. *
Are you on any medication, supplements, meal replacements etc? Please list below.
Your answer
Details of your last medical examination
 i.e date, doctor, general findings (N.B)
Your answer
Any complaints of injuries?
those that can affect your exercise
Your answer
Please Specify Medical History: *
i.e pains, aches, blackout, blood pressure e.t.c that can effect your exercising
Choose
Heart attack 
Heart disease
Lung Disease
Other
None
Do you suffer or take medication for any chronic conditions? *
If Yes, please state the medical condition:
Your answer
Do you consume alcohol? Frequency?
Your answer
Are you a Smoker?
Non, Light, Moderate or heavy
Your answer
Please State your Family Medical History
i.e Heart Attack, Cancer, Diabetic or any other condition
Your answer
I understand that once i sign up for classes for a certain package, i cannot downgrade and if i miss classes it is my loss, we DO NOT CHARGE PER LESSON. WE DO NOT CARRY LESSONS OVER TO THE NEXT SEASON! *
 Important class information will be sent via our Whatsapp Group, please msg 083 786 2787 to be added to this group.
Your answer
Date Signed:
Your answer
Client Contract
By signing this form you agree to the terms and conditions as laid out on website.
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