MI Running & Walking Club 2019 Term 1

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Client 1

Load contact details using username and password
If you do not have a username and password, one will be created for you when you submit this form.

Client Details

Male Female

Parent/Guardian Details

Address

Health and Fitness

Training Dates

From 09-Jan-2019 to 27-Mar-2019

Training Days & Times

Please select up to 12 sessions.
Once a time slot is full you will be asked to make another choice.

Wednesday, 09-Jan-2019 06:00 AM to 07:00 AM Performance Centre, Hegvold Stadium MI Running & Walking Club
Wednesday, 16-Jan-2019 06:00 AM to 07:00 AM Performance Centre, Hegvold Stadium MI Running & Walking Club
Wednesday, 23-Jan-2019 06:00 AM to 07:00 AM Performance Centre, Hegvold Stadium MI Running & Walking Club
Wednesday, 30-Jan-2019 06:00 AM to 07:00 AM Performance Centre, Hegvold Stadium MI Running & Walking Club
Wednesday, 06-Feb-2019 06:00 AM to 07:00 AM Performance Centre, Hegvold Stadium MI Running & Walking Club
Wednesday, 13-Feb-2019 06:00 AM to 07:00 AM Performance Centre, Hegvold Stadium MI Running & Walking Club
Wednesday, 20-Feb-2019 06:00 AM to 07:00 AM Performance Centre, Hegvold Stadium MI Running & Walking Club
Wednesday, 27-Feb-2019 06:00 AM to 07:00 AM Performance Centre, Hegvold Stadium MI Running & Walking Club
Wednesday, 06-Mar-2019 06:00 AM to 07:00 AM Performance Centre, Hegvold Stadium MI Running & Walking Club
Wednesday, 13-Mar-2019 06:00 AM to 07:00 AM Performance Centre, Hegvold Stadium MI Running & Walking Club
Wednesday, 20-Mar-2019 06:00 AM to 07:00 AM Performance Centre, Hegvold Stadium MI Running & Walking Club
Wednesday, 27-Mar-2019 06:00 AM to 07:00 AM Performance Centre, Hegvold Stadium MI Running & Walking Club

DISCLAIMER:
I hereby agree to assume all risks and responsibilities surrounding my (or my child's) participation in the program under the instruction of Movement Improvement coaches. I understand that similar to all sporting activities, there is a risk of damage to personal property, injury or death which may result from causes beyond the control of, and without fault or negligence of Movement Improvement, its officers, agents, or employees, during the period of my (or my child's) participation. I understand completely the above agreement and agree to be bound thereby. By registering on our site you agree that we may send you email related to our facilities and programs. We will not provide your details to any other company.


Agreement

24-Feb-2019

Payment Method

There are no refunds for any enrolments into Movement Improvement related programs. When you sign/tick confirmation for this enrolment you are acknowledging that you know this as a fact and have accepted it as a condition.
$10.00 Casual session (per session)
$100.00 Full term (12 sessions)
$0.00
PayPal (Credit Card or PayPal Account)

The PAR-Q (Physical Activity Readiness Questionnaire) for Safe Exercise

Emergency Contact Name:
Emergency Contact Number:
Emergency Contact Relationship:
Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?
Yes No
Is your doctor currently prescribing drugs/medication (for example, water pills) for your blood pressure or heart condition?
Yes, I am taking medication No, I am not taking anything
Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?
Yes No
Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?
Yes No
Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?
Yes No
If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months?
No, I do not have Diabetes
Yes, I have had trouble controlling my blood glucose
Yes I have diabetes, but have had no issues controlling blood glucose
Do you have any diagnosed muscle, bone or joint problems (for example, back, knee or hip) that you have been told could be made worse by participating in physical activity/exercise?
Yes No
Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?
Yes No
If Yes, please list and explain your medical conditions:
I believe that to the best of my knowledge, all of the information I have supplied within these questions are correct. As well as, I have read and understood the Agreement & Cancellation Policy located below:
Signature of Client or Parent/Guardian if client is under 18:

Agreement & Cancellation Policy

Cancellations:

You need to provide us with notice 24 hours before your session if you want to cancel your training session. After this deadline, it will be considered late and charged as a missed session unless you can change the session to a day and time in the next 7 days.

Full Payment:

You will be invoiced up to 1 week before your first session of a training program. Invoices will cease when the client requests no further training.

Arrive On Time:

If you are late then we will remove exercises from your program to make sure you finish on time

Terms & Conditions

Testing, Program Design & Implementation:

The purpose of any exercise testing is to evaluate health status. There are a variety of tests that may be administered before receiving an exercise program. If you are injured, ill or have any reason why you should not participate, please wait until you are in better condition and notify your practitioner.

The training program that will be supplied to you has been designed to suit your individual training needs. We will always do our upmost to keep our training as safe and effective as possible. Our focus is injury prevention and chronic disease management. 

Attendant Risks and Discomforts:

There exists the possibility of certain changes occurring during exercise testing and programs. These include abnormal blood pressure; fainting; irregular, fast, or slow rhythm; and, instances, heart attack, stroke or death. Every effort will be made to minimise these risks by evaluation of preliminary information relating to your health and fitness and by careful observations during testing and conducting your exercise program. Emergency equipment and trained personnel are available to deal with unusual situations that may arise. 

Responsibilities of the Participant:

Information you possess about your health status or previous experiences of heart related symptoms (e.g. shortness of breath with low-level activity; pain; pressure; tightness; heaviness in your chest, neck, jaw, back, and/or arms) with physical effort may affect the safety of your exercise test. Your prompt reporting of these and any other usual feelings with effort during exercise is very important. You are responsible for fully disclosing your medical history as well as symptoms that may occur during exercise or testing. You are also expected to report all medications (including non-prescription) taken recently and those taken today to the testing or program staff. 

Use of Medical Records:

The information that is obtained during testing and services will be treated as privileged and confidential as described in the Health Insurance Portability and Accountability Act of 1996. It is not to be released or revealed to any individual except your referring physician without your written consent. However, the information obtained may be used for statistical analysis or scientific purposes with your right to privacy retained.

Videos or Photos:

I give permission to Movement Improvement to take and use video recordings or photos for the use of marketing/promotion of the company (e.g. action photos for our webpage).

Goals

What would you like to achieve in your sessions?
Eg. Decrease ankle soreness after walking, improve running efficiency
Do you have a goal or event you are working towards?
(Event and date/timeframe if applicable)