Thankyou for your interest in my Bodyblitz Circuit class.
Please complete the form below and I will confirm your place on the next class.
The information you provide is held in strictest confidence. You can see my full privacy policy at
Note: This physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes so that you would answer YES to any of the questions.
Email address *
Name *
Address *
Date Of Birth *
Phone Number *
Emergency Contact
Emergency Contact Number
Has a Doctor EVER said that you have a Heart condition and that you should only participate in medically supervised physical activity? *
Do you suffer from chest pain during exercise? *
Have you experienced chest pain at any time (not just during exercise) in the last month? *
Do you lose balance or experience dizziness? *
Do you ever lose consciousness? *
Are you currently taking medication for a heart condition or high blood pressure? *
Do you experience shortness of breath with mild exertion? *
Do you have an existing Bone or Joint problem that could be made worse by physical activity? *
Do you suffer with an irregular heart beat? *
Are you pregnant or have you given birth within the last 6 weeks? *
Do you have Diabetes Mellitus? *
Are you aware of any other reasons why you should not exercise without medical supervision or consultation? *
Is there a history of Heart attack or sudden death in any of your parents, siblings or offspring before age 55 (Male) or 65 (female)? *
Is there a history of Heart or coronary artery disease in any of your parents, siblings or offspring before age 55 (Male) or 65 (female)? *
Do you Smoke? *
Have you permanently stopped smoking in the last 6 months? *
Is your Cholesterol level known to be high? *
Is your Blood Pressure known to be high? *
"I have agreed to participate in a programme of physical exercise under the direction of Stuart Owen, which will include but may not be limited to, body weight and/or resistance training. In consideration of appointing Stuart Owen to instruct, assist and train me, I do here and forever release and discharge and hereby hold harmless Stuart Owen, and his respective agents, contractors and employees from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected with my participation in this or any exercise program including any injuries resulting there from. I acknowledge and agree that I assume the risks associate with any and all activities and/or exercises in which I participate. I have read, understood and completed this questionnaire and any questions that I had were answered to my full satisfaction." *
I agree to inform Stuart Owen if I or any member of my household has developed any symptoms (this could include but would not be limited to, a persistent cough, or temperature above 37.8°C, for example) which could be an indication of contracting COVID-19 prior to a class or personal training session starting. *
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