Fitzroy Martial Arts
Fitzroy Martial Arts will take all reasonable and appropriate steps to protect the privacy of individuals as required by the Information Privacy Act 2009 and the Information Privacy Principles contained in that Act.
Client Information Form
Name *
Please include FIRST and LAST name.
Your answer
Date of Birth *
Your answer
Phone *
Mobile and or home number
Your answer
Address *
Your answer
Email *
Your answer
Gender *
Do you have Private Health Insurance?
If yes, what health fund?
Your answer
Emergency Contact *
Full name and number
Your answer
PRE-EXERCISE SCREENING
To identify those individuals with a known disease, or signs or symptoms of disease, who may be at a higher risk of an adverse event during physical activity/exercise.
Do you have any medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?
If so please specify
Your answer
How did you hear about Fitzroy Martial Arts? *
If you were referred by a friend, please provide their name below so we can thank them.
Required
What are your goals for training with Fitzroy Martial Arts? *
If you have a specific date for your goal, please detail below
Required
What disciplines are you interested in training at Fitzroy Martial Arts? *
Tick all that apply
Required
I have read and agree to the rules, regulations, policies and procedures at fitzroy martial arts. *
Required
WAIVER & RELEASE *
I hereby acknowledge that whilst on the premises, my person and property are at my own risk. I acknowledge that I will not hold Fitzroy Martial Arts responsible for and hereby excludes, to the extent permitted by law, all liability for any personal injury or damage (whether direct or indirect, special or consequential) suffered by me or loss of property while I am on the premises or arising in any way out of the facilities and equipment provided, however that injury, damage or loss is caused, including if it is caused by Fitzroy Martial Arts negligence. I acknowledge that except as provided in this document, Fitzroy Martial Arts gives no warranties in respect of the facilities and equipment it provides. I hereby release and will indemnify and keep indemnified Fitzroy Martial Arts and all associated entities for any injury of loss suffered by me whilst on the premises. This includes my participation in any and all Fitzroy Martial Arts activities and programs, including representation of Fitzroy Martial Arts. This agreement shall apply to all of my future visits to Fitzroy Martial Arts.
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