YOUR DETAILS
First Name*

Surname*

Email*

Mobile/Phone*

Date of Birth*

EMERGENCY CONTACT
Their Full Name*

Mobile/Phone*

HEALTH INFORMATION
Please Note: this information is important to us, so answer truthfully, as it will help us assess your readiness for training. If in doubt, please include any details below, in which we may discuss with you before your training sessions.

Do you have any major past injuries? NoYes

Do you have any current injuries? NoYes

Have you got or do you have any family history of heart disease? NoYes

Have you got or do you have any family history of arthritis or osteoporosis? NoYes

Have you got or do you have any other family history of diseases? NoYes

Are you on any medication, past or present, that may impact your training? NoYes

Do you have high blood pressure? NoYes

Do you have or have had asthma? NoYes

Are you pregnant or have you been pregnant in the past? NoYes

Please describe further in the text box below if you answer YES to any of the questions in this section.

DISCLAIMER
Geelong Kettlebell Sport Association (and associate parties) strongly recommends that you consult with your Doctor/physician before beginning an exercise program. You should understand that when participating in any exercise or exercise program, there is the possibility of physical injury and/or death. If you engage in this exercise or exercise program, you agree that you do so at your own risk. You are voluntary participating in these activities, assume all risk of injury to yourself and agree to release and discharge GKSA (and associate parties) from any and all claims or causes of action, known or unknown, arising out of our guidance.

Do you agree to the above disclaimer, and that all your above details are true, and that you are prepared for exercise? YesNo

Signature (type your full name to sign)*