Waiver. Date * MM DD YYYY Name * First Name Last Name Date of Birth * MM DD YYYY Email * Phone * (###) ### #### Occupation * Address * Emergency Contact (Name & Number) * Please check if you are experiencing or have in the past experienced any of the following medical conditions * Dizziness Fainting Stroke Diabetes Arthritis Epilepsy Glandular Fever Heart Attack Asthma Chronic Fatigue Panic Attacks Kidney Ailments Heart Condition Low Blood Pressure Infectious Disease MS Circulation problems Chest Pains Bone Disorder Blood Clots Heart Murmer Mental Illness Inflammation None of the above Please note any injuries/ medical conditions that may not be outlined above * Are you on any medication? If yes, please give details and confirm that you have been cleared by your medical practitioner to train * Have you been hospitalised in the last 12 months? If yes, please give details * Do you have any joint injuries? If yes, please give details * Do you have any soft tissue injuries (strains, tears, etc)? If yes, please give details * Prime Athletica strongly recommends that before you undertake any instructed activity, that you should first undergo a wide-ranging and complete physical examination from a registered medical practitioner, to ensure that you are fit and able to commence your exercise program. You should advise your medical practitioner, that the exercise program includes weight lifting, circuit training, aerobic and anaerobic exercise over prolonged periods of time. * I have read and acknowledge the above PRIVACY STATEMENT AND ACKNOWLEDGEMENT * You acknowledge that in completing this form, you will disclose to us information about you that is accurate and true to the best of your knowledge, including information relating to your health. We agree to handle this information with care, professionalism and in accordance with the Privacy Act 1988. By checking the below box, I acknowledge that engaging in physical activity may lead to serious or disabling injuries, even death. I understand that all activities in any exercise program are optional and I may stop at any time. I release PRIME ATHLETICA, its employees and its sub-contractors from all liability for any injury, which I may suffer whilst participating in any activities howsoever caused at Prime Athletica. I assume with full knowledge the dangers of participation in any fitness activities and do so at my own risk. I acknowledge that there are surveillance cameras in all common areas of Prime Athletica, including the reception, the gym floor and in the studio space on the first-floor. I acknowledge that I have read and understood all of the terms and conditions of this agreement prior to signing the agreement and that the information I have given is complete and true to the best of my knowledge. I have read and acknowledge the above 1 PERSONAL TRAINING CANCELLATION POLICY Please take the time to read this cancellation policy for PRIME ATHLETICA thoroughly as it is strictly adhered to at all times. If you are unsure or have any questions regarding the following, please do not hesitate to contact your personal trainer to discuss the matter further. PRIME ATHLETICA requires a minimum of 12 hours notice for cancellation of a session. Failure to do so will result in the client forfeiting their paid session. Emergency and special circumstances will be considered on a per case basis and while every effort will be made to make-up these sessions, PRIME ATHLETICA holds no obligation to do so. However, this policy works both ways. If your personal trainer is unable to notify you 12 hours prior to a session of their intention to reschedule or cancel, the client is entitled to an additional, complimentary session. I have read and acknowledge the above Thank you!
