Body and Balance Enrollment Form

First Name

Last Name

Date of Birth

Sex

Male Female Other

Address

Phone Number

In Case of Emergency

Name

Relationship

Phone

Pre-Exercise Questions

While Body and Balance exercise is designed for all
levels of Fitness, it is important to check with your Doctor
before commencing and let the instructor know of
any medical conditions.
This is particularly important if you are or recently have
been pregnant, injured or ill
Please read and complete the following questionnaire carefully

Medical Conditions

Is there any condition(s) that could affect your ability to
exercise?
(for example Stroke, Heart Condition, High Blood Pressure
>140/90, Palpitations, Diabetes, Epilepsy, Rheumatic
Fever, Arthritis, Cramps, Asthma or Neck, Ankle, Back,
Knee and Muscular Pains).