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
Please include FIRST and LAST name.
Date of Birth
Mobile and or home number
Do you have Private Health Insurance?
If yes, what health fund?
Full name and number
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
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.
What are your goals for training with Fitzroy Martial Arts?
If you have a specific date for your goal, please detail below
Cross-training for other sport
Manage health condition
What disciplines are you interested in training at Fitzroy Martial Arts?
Tick all that apply
Brazillian Jiu Jitsu
I have read and agree to the rules, regulations, policies and procedures at fitzroy martial arts.
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.
I am over 18 and assuming full responsibility
No, i am a child so my parent will sign below
Page 1 of 1
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service