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"*" indicates required fields

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Name*
DD slash MM slash YYYY
Gender
First line of your address*
Address line 2 if required
City*
Post code*
Do you have high blood pressure?*
Do you currently experience any pains in your chest when you undertake physical activity?*
Have you previously suffered from chest pains during physical activity?*
Do you lose your balance because of dizziness?*
Do you ever lose consciousness?*
Do you have a bone or joint problem that could be made worse by a change in your physical activity?*
Are you currently taking any prescribed medication excluding the contraceptive pill?*
Do you know of any reason why you should not be undertaking physical activity?*
Doctors consent*
If you have answered any of the above questions with a yes you will need to consult with your GP BEFORE you start becoming more physically active. We will need written confirmation from your GP before you begin using the gym.
Declaration*
I have read, understood and completed the above questionnaire and acknowledge that there are risks and dangers inherent in physical exercise and duly undertake the activity at my own risk. Any liability on the part of the operators is excluded unless negligence can be proven. I agree to observe the rules and conditions of membership. I also acknowledge that I must not use any piece of equipment for which I have not been shown how to use by an instructor. I confirm that the information which I have provided is correct at this time and should I become aware of any relevant changes to my health or condition, I will inform a member of the Power coaching team.