Pulse Fitness Gym - Membership Form

Required fields are marked with an asterisk (*).

Title *

First Name *

Last Name *

Gender *

Date of Birth *

Street Address * Including Suburb

Post Code *

Email *

Mobile Number *

Are you an existing member? *

Emergency Contact Information

Name *

Relationship *

Address *

Mobile Number *

PRE-EXERCISE SCREENING SYSTEM - This screening tool is designed to assess whether you need further advice from an allied health professional or medical practitioner before commencing an exercise program or engaging in any physical activity within this complex. This screening tool does not provide advice on a certain matter, nor does it substitute for advice from an appropriately qualified medical professional. No warranty of safety should result from its use. This screening tool in no way guarantees against injury or death. No responsibility or liability whatsoever can be accepted by Pulse Fitness, Roxbylink, or Roxby Downs Council 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.

1. Has your medical practitioner ever told you that you have a heart conditions or have you ever suffered a stroke? *

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

3. Do your ever feel faint, dizzy or lose balance during physical activity/exercise? *

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

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

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

If you answered "YES" to any of the above 6 questions, we will require written advice from your allied health professional or medical practitioner. Please note until this has been received by Pulse Fitness, you will not be able to utilise our facilities.

Written advice from your allied health professional or medical practitioner Can be uploaded below, provided in hard copy or emailed to gym@roxbylink.com.au prior to your first visit.

Agreement

I have read and understood the Terms and Conditions of Membership and agree to abide by them for the term of my membership. I believe to the best of my knowledge that the information I have provided in this tool to be accurate and correct. * Terms and Conditions of Membership available to read on the 'sign up for your membership' page: https://www.roxbydowns.sa.gov.au/lifestyleandsport/pulse-fitness-gym/sign-up-for-your-membership

Lifestyle & Sport

Pulse Fitness Gym - Membership Form

Contact Council

Connect with Roxby Council

Connect with Roxby Link