PT & Group Training Registration Form 2017
Registration for all new members or members returning after a break of 3+ months. Any questions, email, text or call me.
/ 04 52 42 3056
Emergency Contact Person Details
Name of emergency contact person & relationship to you:
Best contact number
PLANKING PARENTS AND THEIR TEENS
Please detail below any illnesses, injuries, hospitalisations or surgical procedures you have had AND/OR planning to have:
Have you suffered from any of the following?
Please tick any of the applicable options
Any cardiac condition (give further details below)
Stroke/TIA (transient ischaemic attack/mini stroke) (detail below)
Abnormal or resting stress ECG
Uneven, irregular or skipped heart beats, including a racing or fluttering heart.
High blood pressure/hypertension
Low blood pressure/hypotension
Pulmonary/Respiratory disease (asthma, emphysema and bronchitis)
Light headedness or fainting
Seizures and/ or epilepsy
Chest pain at rest or exertions
Unusual shortness of breath
Orthopaedic problems (including but not exclusively, arthritis, any other bone, joint or muscle problems)
Phlebitis (Deep Vein Thrombophlebitis)
Family history of heart attack
(Please add details in the box below if you have a genetic pre-disposition to heart attack)
Any post partum issues
If you ticked any of the above, please give further details in the box below.
Do you know of any other reason why you should not participate in challenging physical activity? OR any reason why your participation would require modification?
If you answered yes to the above, please give details below.
Gender Specific Questions
Tick any below that are applicable to you.
Are you a male over 35years new to exercising?
Are you female over 45 years new to exercising?
Are you female post-menopausal?
Are you trying to conceive?
Have you recently (within the last 12months) given birth/delivered?
Have you experienced any post partum issues/
Please tick below
Do you smoke?
Do you drink alcohol?
Do you drink caffeinated beverages? (coffee, tea, energy drinks)
If you answered yes to any of the above, please detail your average daily or weekly consumption.
How would you rate your daily activity level?
Medication (prescribed by a health practitioner or otherwise)
Please detail any prescribed medications/supplements you take:
Please detail any non prescribed medications/supplements you take:
Please detail any allergies and associated action plans (food, medications, pollens etc.):
Please detail any anaphylaxis and associated action plans (food, medications, pollens etc.):
Health and Fitness Goals
Please tick the goals applicable to you.
Increase physical activity for the whole family
Participation in a fitness event
Improve sports related movements
If you answered YES to any of the above, you may give further details in the box below.
What are your short term goals?
What are your long term goals?
Are you currently exercising? Please detail below.
Please list your exercising history.
Tracking Progress (optional)
Recording your measurements is a great way to track your progress, which can provide motivation when needed and help you set targets and rewards for those met. Key to successful measuring and re-measuring is consistency, i.e. taking measurements at the same place on the body, at the same time of day, wearing the same clothes. Please consider taking your Resting Heart Rate. This is an excellent means of monitoring your fitness level and an indicator of cardiovascular health.
Stand with arms straight and palms of hands pointing down, measure thigh where the middle finger tip touches leg.
Stand straight weight through heels and measure at widest point.
Stand straight, weight through heels and measure at the widest point
Do not suck your belly in, measure at the belly button.
Measure in line with the nipple. For woman, wear the same bra for each measure and future measures.
Flex bicep and measure at widest point
Always weigh yourself at the same time of day, roughly the same clothes and for woman the same day in your cycle.
One off measurement
Complete these is you would like results sent to you.
Resting Heart Rate
A great indicator of cardiovascular health. Take your pulse before rising, eating or drinking in the morning for 1 minute. Ideally do this three times and record the median.
Hip to Waist Ratio
Tick Yes or No if you would like to be sent your ratio. A good indicator of general health, identifying problems with excess body fat and a heart health indicator.
If the client training is under 18yrs of age, this section must be completed by their parent and/or legal guardian. It is the responsibility of the parent and/or legal guardian to ensure that the client understands the waivers below.
By answering yes in the box below I assume all responsibility for my/my child's health and well-being and do not hold responsible Monkey See, Monkey Do! Family Fitness or Kathryn Montgomery the instructor, or anyone acting on her behalf, the facility or any persons involved with this program and testing procedures.
I understand that I/my child are not obligated to perform nor participate in any activity that I/they do not wish to do, and that it is my/their right to refuse such participation at any time during the training sessions. I understand that should I/they feel light-headed, faint, dizzy, nauseated, or experience pain or discomfort, I/they are to stop the activity and inform the Trainer. I give Kathryn Montgomery and the staff at the facilities at which we train, permission to seek emergency medical services for me should I become injured or ill with the understanding that I am responsible for any expenses incurred.
I understand that I am wholly responsible for the safety & welfare of my children while training with Monkey See, Monkey Do! Family Fitness/Kathryn Montgomery or any person acting for her. I understand that Kathryn Montgomery or any person acting for her, is in no way responsible for my children during my attendance & participation.
If there is anything else you would like to tell me that impacts on your participation in physical exercise, please use the section below.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service