Section 1

Name

First Name

Last Name

Email Address

Phone

Include best time of day to call

Gender

MALE

FEMALE

Age

Height (cm)

Weight (kg)

How did you find out about Leftfield Training

Briefly describe your specific short-term goals. (within 15 weeks)

Do you have any dietary restrictions?

Are you currently following any exercise or dietary program?

Are you interested in Private or Semi-Private training?

If interested in Semi-private training, each person (maximum of 3) must complete a separate form

Private

Semi-private

Do you have any injuries?

Please list details

Section 2

ADULT PRE-EXERCISE SCREENING TOOL

The following questions make up Stage 1 of the Adult Pre-Exercise Screening Form (APSS)

This screening tool does not provide advice on a particular matter, nor does it substitute for advice from an appropriately qualified medical professional. No warranty of safety should result from its use. The screening system in no way guarantees against injury or death. No responsibility or liability whatsoever can be accepted by Exercise and Sports Science Australia, Fitness Australia or Sports Medicine Australia for any loss, damage or injury that may arise from any person acting on any statement or information contained in this tool. AIM: To identify individuals with known disease, and/or signs or symptoms of disease, who may be at a higher risk of an adverse event due to exercise. An adverse event refers to an unexpected event that occurs as a consequence of an exercise session, resulting in ill health, physical harm or death to an individual. This stage may be self-administered and self-evaluated by the client. Please complete the questions below.

Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?

YES

Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?

YES

Do you ever feel faint, dizzy or lose balance during physical activity/exercise?

YES

Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?

YES

If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months?

YES

Do you have any other conditions that may require special consideration for you to exercise?

YES

IF YOU ANSWERED ‘YES’ to any of the 6 questions, please seek guidance from your GP or appropriate allied health professional prior to undertaking physical activity/exercise

IF YOU ANSWERED ‘NO’ to all of the 6 questions, and you have no other concerns about your health, you may proceed to undertake light-moderate intensity physical activity/exercise

Section 3

Agreement for Participating in Personal / Group Strength, Fitness and Conditioning Training.

The ‘Trainer’ refers to the Australian Registered Business ‘Leftfield OutdoorTraining’ The ‘Activity’ refers to the participation in personal / group strength, fitness and conditioning training and general advices.

I acknowledge that it is a condition of participating in this activity that I do so at my own risk I accept all risks and hereby indemnify and release the Trainer, their agents, affiliates, employees, members, sponsors, promoters and any person or body directly and indirectly associated with the Trainer, against all liability (including liability for their negligence and the negligence of others) claims, demands, and proceedings arising out of or connected with my participation in this activity. This release and indemnity continues forever and binds my heirs, successors, executors, personal representatives and assigns. I acknowledge that participating in this activity may involve a risk of serious injury or even death from various causes including: over exertion, dehydration, equipment failure, and accidents with equipment and surroundings. I recognise the difficulties associated with the activity and attest that I am physically fit to participate safely in the activity and that a qualified medical practitioner has not advised me otherwise. I understand the demanding physical nature of this activity. I am not aware of any medical condition, injury or impairment that will be detrimental to my health if I participate in this activity. In the event that I become aware of any medical condition, injury or impairment that may be detrimental to my health if I participate in this activity my Trainer will be immediately informed. By continuing to participate in this activity, I accept the risks despite these conditions and am still, and always will be under the terms of this agreement. I certify that I am 18 years or older and have read this document fully and understand it OR As a parent or guardian of the participant (a) I agree to the above for myself and on behalf of the participant and (b) I indemnify and will keep indemnified any person or body directly or indirectly associated with the conduct of the activity on the terms referred to.

I agree to the terms as listed above and by submitting this form I declare that to the best of my knowledge all information supplied is true and correct.

YES