Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Title *MrMrsMissGender *MaleFemaleName *FirstLastEmail *EmailConfirm EmailOcccupation *CompanyDoctor's NameEmergency Contact *Do you have private health insurance? *YesNoWhich fund? *How did you find out about our Event? *1. Have you ever or do you have any of the following? *Heart DiseaseCardiovascular ConditionDizzinessBlackoutsFaintingAsthmaHigh/Low Blood PressureArthritisDiabetesEpilepsy/FitsGoutFamily History of Heart DiseaseInfectious diseasesOtherPlease specify? *2. Do you have any problems/injuries in the follow areas? (please tick and explain to the best of your ability) *KneesLower BackNeck/ShouldersHips/PelvisFlexibilityOtherPlease explain? *3. Are you pregnant? *YesNoHow many weeks? *4. Are you currently doing any regular physical activity? *YesNoWhat and how many times per week? *5. Have you had surgery in the last 5 years? *YesNoWhen & what? *6. Do you smoke? *YesNoHow many per day? *For how how long have you smoked? *7. Are you on any medication? *YesNoWhat and when do you take? *8. Anything else we need to know? (if unsure write it down) *ACKNOWLEDGEMENT RELEASE AND ASSUMPTION OF RISK *I have read the information below and acknowledged and know how it affects my legal rights.Warning: This is an important document, which affects your legal rights and obligations. Please read it carefully and do not agree to it unless you understand it. If you have any questions, please ask. Acknowledgment of Risks, Injury and Obligations I acknowledge that the activities I am to undertake have potential dangers and by participating in them I am exposed to certain risks. I acknowledge and understand that whilst participating in any such activities: I may be injured physically, mentally or may die; Any physical conditions I may have, of which I may or may not be aware of, which I may or may not have disclosed to the centre or its staff, may be aggravated or worsened by my participation; My personal property may be lost or damaged; Other persons participating in such activities may cause me injury or may damage my property; I may cause injury to other persons or damage their property; The conditions in which the activities are conducted may vary without warning; I may be injured or die or suffer damage to my property as a result of negligence or breach of contract of the Event Organizers, or its servants or agents; and There may be no or inadequate facilities for treatment or transport of me if I am injured. I assume the risk of, and the responsibility for any injury, illness, death or property resulting from my participation in any activities. Release and Indemnity to Event Organizers In the consideration of the acceptance of my interest for participating in any activity (except to the extent that the event organizers may be precluded by statute) I agree to release and indemnify the Event Organizers and staff as follows: I participate in the activities at my sole risk and responsibility; and I release, indemnify and hold harmless the Event Organizers, its servants and agents, from and against all and any actions or claims which may be made by me or on my behalf or by other parties for or in respect of arising out of any injury, loss, damage or death caused to me or my property whether by negligence, breach of contract or in any way whatsoever. I also agree that in the event that I am injured or my property is lost or damaged, I will bring no claim, legal or otherwise, Before submitting this document, I have read and acknowledged and know how it affects my legal rights.Submit