Empower Me Fitness Classes Enrollment Form
Enrollment form for Mums & Bubs classes with Caren Van Gastel at Empower Me Fitness & Consulting.

First time enrolment? - please answer all questions.
Returning for another term? - please confirm preferred class time and update any details as required.
Email address *
Which class are you enrolling in?
Name
Date of Birth
MM
/
DD
/
YYYY
Phone Number
Address
Emergency contact name & phone number
Occupation (prior to baby)
Name and DOB of your Child/ren
Have you ever had or do you have?:
Are you currently pregnant? If yes, how many weeks?
If pregnant, do you experience Pelvic Girdle pain or symphasis pubis dysfunction?
Clear selection
Delivery type (previous births)
Clear selection
Any instruments used or complications from delivery?
How big was your baby at birth?
What was your gestation age at delivery for your most recent birth?
Are you still experiencing any bleeding post birth?
Clear selection
Are you currently breastfeeding?
Clear selection
Are you on any prescribed medication? If yes, what and how often?
Do you have any current/previous injuries? If yes, please provide details of the injury & when it occurred.
Pelvic Health - Do you experience any of the following:
Have you seen, or are you seeing a Women's Health/Pelvic health physio for any of the above?
Clear selection
What exercises/activity (if any) did you do whilst pregnant? How often?
Have you done any exercises/activity since birth? If so, what and how often?
Health & Fitness goals - what would you like to get out of these classes?
What type of exercises do you love to do?
What type of exercises do you dislike doing?
How did you hear about these Mums & bubs classes?
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