Aquacise Registration Form And Health Questionnaire

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Adult Aquacise Registration Form

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First Name *

Last Name *

Gender *

Male
Female

Age *

Telephone Number Daytime *

Telephone Number Evening *

Address *

Your Email *

Email

Confirm Email

Please Indicate What You Hope To Gain From Aquacise Classes *

Days And Times You Would Be Unavailable To Attend ? Mon-Friday 9am - 7pm *

How Many Times Per Week Do You Excercise? *

None
1 - 2
3 - 4
5 - 6
More Than 6

What Type Of Exercise Do You Currently Undertake? *

Do You Have Any Joint Problems? *

Yes
No

Do You Have Any Muscular Problems? *

Yes
No

Do You Have Any Respiratory Problems? *

Yes
No

Do You Have Any Circulation Problems? *

Yes
No

Are You Currently Taking Any Medication? *

Yes
No

Any other Health Issues ( Inc Pregnancy ? *

Are You Water Confident And Happy In All Depths Of Water? *

Yes
No

Do You Know Of Any Reason Why You Should Not Partake In Aquacise Classes? *

Yes
No

If You Have Answered Yes To Any Of The Above Medical Questions, Please Confirm That You Have Sought Medical Advice, As Appropriate, About Taking Part In The Aquacise Classes. *

I Fully Understand

Do You Give Permission For Photos/Videos Of You To Be Used For Promotional Purposes Inc Social Media? *

Yes
No

How Did You Hear About Us ? *

I Agree To Aquability Inc Terms And Conditions Inc Including Disclaimer Featured On The Website *

Yes

Additional Notes

Please Enter Your Full Name As This Will Be Your Electronic Signature *

Todays Date *

Safety Notice: Please Note That It Is Always Best Practice To Apply Common Sense When Starting A Different Form Of Exercise. The Questions On This Sheet Will Enable The Instructor To Understand Your Needs And Requirements During The Classes. *

I Fully Understand

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