Home Visits Form

First Name

Surname

Contact Number

Gender

Email Address

Date

Height

Weight

Do You Struggle with Blood Pressure

Select the Package you would like to take

Sunday

Work Hours

Unavailable Times

Preferred Training Time

Monday

Work Hours

Unavailable Times

Preferred Training Time

Tuesday

Work Hours

Unavailable Times

Preferred Training Time

Wednesday

Work Hours

Unavailable Times

Preferred Training Time

Thursday

Work Hours

Unavailable Times

Preferred Training Time

Friday

Work Hours

Unavailable Times

Preferred Training Time

Saturday

Work Hours

Unavailable Times

Preferred Training Time

Please Select which Goals you would like to achieve? Hold CTRL to select more than one.

Other Goals

Has your doctor ever said that you have a heart condition and you should only do physical activity recommended by a doctor?

Yes No

Notes

Do you feel pain in your chest when you do physical activity?

Yes No

Notes

In the past month, have you had chest pain when you were not doing physical activity?

Yes No

Notes

Do you lose your balance because of dizziness or do you ever lose consciousness

Yes No

Notes

Do you have a bone or joint problem (e.g. back, knee, etc.) that could be made worse by a change in your physical activity?

Yes No

Notes

Is your doctor currently prescribing medication for your blood pressure or heart condition?

Yes No

Notes

Do you know of any other reason why you should not engage in physical activity?

Yes No

Notes

Is medical clearance required?

Yes No

Notes

I understand that if I answered YES to one or more of the above questions, I should have the consent of my doctor before undertaking a physical activity programme.

Photography/Video Release

Participants involved in any activities offered by FIT CULTURE SA may be photographed or video recorded during said activities. The undersigned hereby consents to the use of these photographs and/or videos without compensation, on the FIT CULTURE SA website or in any editorial, promotional or advertising material produced and /or published by FIT CULTURE SA and our members/affiliates.

Waiver and Release of Liability

I, the undersigned, am aware that there are significant risks involved in all aspects of physical training. These risks include, but are not limited to: falls which can result in serious injury or death; injury or death due to negligence on the part of myself, my training partner, or other people around me; injury or death due to improper use or failure of equipment; strains and sprains. I am aware that any of these above mentioned risks may result in serious injury or death to myself and or my partner(s).

Waiver and Release of Liability

I willingly assume full responsibility for the risks I am exposing myself to and accept full responsibility for any injury or death that may result from the participation in any activity or class while at FIT CULTURE SA, or under direction of FIT CULTURE SA members/affiliates.

Waiver and Release of Liability

I acknowledge that I have no physical Impairments, injuries, or illness that will endanger me or others.

Release

In consideration of the above mentioned risks and hazards and in consideration of the fact that I am willingly and voluntarily participating in the activities offered by FIT CULTURE SA , I, the undersigned hereby release FIT CULTURE SA, their principals, agents, members, affiliates employees, and volunteers from any and all liability, claims, demands, actions or rights of action, which are related to, arise out of ,or are in any way connected with my participation in this activity, including those allegedly attributed to the negligent acts or omissions of the above mentioned parties. This agreement shall be binding upon me, my successors, representatives, heirs, executors, assigns, or transferees. If any portion of this agreement is held invalid, I agree that the remainder of the agreement shall remain in full legal force and effect. If I am signing on behalf of a minor child, I also give full permission for any person connected with FIT CULTURE SA to administer first aid deemed necessary, and in case of serious illness or injury, I give permission to call for medical and or surgical care for the minor to a medical facility deemed necessary for the well-being of the minor.

Home Visits Form

MEMBERSHIP INFORMATION

Item Name

1 Session per week

2 Sessions per week

Monthly Fee

R800.00

R1 400.00