FITLIFE Otara Registration Form
FITLIFE Otara Community Health and Fitness initiative fully funded by Total Health Care Otara for communities in South Auckland

The sessions are held 6am-7am every Monday, Wednesday and Friday starting on Monday 23rd of March - Friday 15th of May 2020

Venue is the Manukau Tennis Centre which is in the Manukau Sports bowl grounds 1 Te Irirangi Dr, Clover Park

Registrations will close Thursday 19th of March 2020 or when capacity numbers are reached.

The FITLIFE programme is funded by Total Healthcare PHO who also funds the Local Doctors and White Cross Clinics. The FITLIFE initiative is designed and delivered by D65 Fitness, our vision is to Empower our Otara and surrounding Communities to live a healthier lifestyle.

First Preference will be for those that are
1) Registering for their first FITLIFE Challenge
2) Those that have completed 70% or more of the previous FITLIFE Challenge.
All others will be on a waiting list and confirmed on Thursday 19th of March 2020

Please ensure all contact details are correct and current as we will use the contact details you enter as the main form of contact when we send your confirmation email.

Please note that all your information is kept confidential within the FITLIFE database only and will not be used for any other marketing purposes. Please provide accurate and up to date contact details as your information will be used for your emergency purposes and for FITLIFE to keep you updated with the program.  
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HOME 4 THE DOME DONATION for the cost of a cup of coffee a week you can help build the home for the dome. If you would like information to how you can help us continue to change the health of our communities please tick the box below *
Captionless Image
Required
Full Name *
Home Phone *
Mobile *
Address *
Suburb *
Post Code *
Best Contact Email Address *
Gender *
Required
Age Group *
Date of Birth *
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/
DD
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YYYY
Ethnicity *
Required
If Maori, which Iwi do you belong to?
Details of Emergency Contact *
Full Name
Home Phone *
Mobile *
Your current physical condition *
Required
How many times a week are you doing physical activity *
Required
List the type of physical activity you are currently doing e.g. weight training, sports, swimming etc
What are the main goals you want to achieve from the FITLIFE programme *
Required
Why are these goals important to you? *
PAR Q (Physical Activity Readiness Questionnaire *
Has your doctor ever said you have a heart conditionand that you should only do physical activity recommended by a doctor?
Required
In the past month, have you ever had chest pain when you were not doing exercise? *
Required
Do you feel pain in your chest when you do physical activity? *
Required
Do you lose balance because of dizziness or do you ever lose consciousness? *
Required
Do you have a bone or joint problem(e.g. back knee or hip) that could be made worse by a change in your physical activity *
Required
If Yes, where is your joint problem
Is your doctor currently prescribing you drugs for blood pressure or heart condition? *
Required
If yes, what medication and for what condition
Do you know of any other reason why you should not do physical activity? *
Required
If you answered yes to one or more of the above PAR Q questions
Talk with your doctor by phone or in person BEFORE you start becoming more physically active or BEFORE you do a fitness test. Tell your doctor about this test and which questions you answered Yes to. You may be able to do any physical activity you want - as long as you start slowly and build up gradually. Or you amy need to restrict your activitiesto those which are safe for you. Talk with your doctor and follow his/her advice. Find out which programmes are safe and helpful to you
If you answered No to all the above PAR Q questions
If you answered NO honestly to all  PAR – Q questions, you can be reasonably sure that you can: • Start becoming much more physically active – begin slowly and build up gradually. This is the safest and easiest way to go. • Take part in a fitness appraisal – this is an excellent way to determine your basic fitness so that you can plan the best way for you to live actively. It is also highly recommended that you have your blood pressure evaluated. If your reading is over 144/94, talk with your doctor before you start becoming much more physically active.
Delay becoming much more active
• If you are not feeling well because of a temporary illness such as a cold or fever – wait until you feel better; or • If you are or may be pregnant – talk to your doctor before you start becoming more active.
Please note:
If your health changes so that you then answer YES to any of the above questions, tell your fitness or health professional. Ask whether you should change your physical activity plan.
Physical Activity Questions *
I am regularly active and have been for more than 6 months
Required
I am not regularly active but I have plans to becoming physically active in the next month *
Required
I am not regularly physically active but I intend to change my inactive life style in the next 6 months *
Required
Have you had major surgery or have been hospitalised due to injury or health in the last 12 months? *
Required
If Yes, please explain
Please Tick the following conditions you may have
Clear selection
Please describe if any of the above conditions are in your family history
Do you smoke? *
Required
if Yes, how many per day?
Have you participated in a FITLIFE Challenge before? *
Required
Are you registered with a East Tamaki Healthcare Clinic? *
Required
How did you hear about the FITLIFE Programme?
Waiver
I understand the safety screening questionnaire, and have answered honestly to the best of my knowledge. D65 fitness Ltd will provide me with a safe and effective fitness program based on the information I have given, I understand there is risk involved and take full responsibility for my actions. D65 Fitness Ltd, East Tamaki Health Care and all its associate companies shall not be liable or responsible for any injuries to me resulting in my participation in the FITLIFE Otara programme.
Signature
Typing your name will be sufficient
Date
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