Name

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Sex

Male

Female

How Did You Hear About Us *

From a Friend/Family Member

Location

Social Media

Print Advertising

Website

Google Search

Other

Emergency Contact Name

First Name

Last Name

Have you tested positive to COVID 19/Corona Virus

Yes

No

Have you displayed symptoms consistent with COVID 19 in the past 14 days? *

YES

NO

Have you recently arrived from and international location within the last 14 days? *

YES

NO

Have you associated with someone that has tested positive for COVID 19 in the past 14 days? *

YES

NO

Have you associated with someone that has arrived from an international location with in the past 14 days? *

YES

NO

Do you have any reason to believe that you may have been exposed to COVID 19 or that your presence in the gym may put others at risk? *

YES

NO

Heart Conditions *

Yes

No

Diabetes *

Yes

No

Skeletal Problems/Abnormalities *

Yes

No

Join Injuries or Degeneration *

If yes please explain:

Yes

No

High Cholesterol

Yes

No

Cancer (past or present)

If yes please explain:

Yes

No

Stroke or Fam. History of Stroke

If yes please explain:

Yes

No

Hernia

Yes

No

Low Blood Pressure *

Yes

No

Epilepsy

If yes please explain:

Yes

No

Do you Smoke? *

Yes

No

Do you have family history of Heart Disease?

Yes

No

Have you had any major surgeries in the past 12 months?

If yes please explain:

Yes

No

Are you taking any perscribed medication? *

If yes please explain:

Yes

No

Are you planing on becoming pregnant in the next 8 weeks?

Yes

No

Do you partake in regular exercise? *

Yes

No

Members Name

First Name

Last Name

Will We See You This Week? *

Yes

No

What Day Can We Expect You? *

Monday

Tuesday

Wednesday

Thursday

Friday

What Time Can We Expect You *

3pm-5pm

5pm-7pm

Clause (2) Agreement *

I have read and understand Clause (2)

Yes

No

Clause (5) Agreement *

I have read and understand Clause (5)

Yes

No

Clause (12) Agreement *

I have read and understand Clause (12)

Yes

No

Clause (13) Agreement *

I have read and understand Clause (13)

Yes

No

1. I agree to practice social distancing where practicable. *

Yes

No

2. I agree to sanitize equipment after use and clean excess sweat from training area. *

Yes

No

3. I agree to always use a towel and wear clear exercise wear. *

Yes

No

4. I agree to inform staff IMMEDIATELY if I suspect that I have or have been in contact with someone who has tested positive for Covid 19/Corona Virus. *

Yes

No

5. I understand that staff may ask me to leave if I do not follow Covid Safe Practices. *

Yes

No

Name

First Name

Last Name

Clause (1) Agreement *

I have read and understand Clause (1)

Yes

No

Clause (1A) Agreement *

I have read and understand Clause (1A)

Yes

No

Clause (1B) Agreement

I have read and understand Clause (1B)

Yes

No

Clause (1C) Agreement *

I have read and understand Clause (1C)

Yes

No

Clause (2) Agreement *

I have read and understand Clause (2)

Yes

No

Clause (6) Agreement *

I have read and understand Clause (6)

Yes

No

Name

First Name

Last Name