Name *

First Name

Last Name

Phone *

(###)

###

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

EMERGENCY CONTACT *

First Name

Last Name

Contact Number *

(###)

###

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HAVE/DO YOU EXPERIENCE ANY OF THE FOLLOWING *

Please check all that you currently experience or have experienced in the past.

High or low blood pressure

Heart or lung condition

Asthma or breathing condition

Dizziness or fainting spells

Diabetes

Epilepsy

Autoimmune disease or hormonal dysfunction

High cholesterol

Hernia

Muscular or joint pain (inc. arthritis)

Injury that is recent or still impacting movement or causing pain or discomfort at any time

Allergy (eg: bees/nuts)

Other

NONE OF THE ABOVE

MENSTRUATION AND CHILDREN *

Please select any that apply to you

Painful ovulation or menstruation

Pelvic or back pain during menstruation or ovulation

Pelvic floor dysfunction or symptoms (bulging, dragging, heaviness)

Vaginal birth

Cesarean birth

Abdominal separation

Painful scar site

Anything else

NONE OF THE ABOVE

SOCIAL MEDIA *

Do you consent to videos and/or photos of yourself being used on social media? (Please note: I will never take or post any media of your children)

YES I consent

NO I do not consent

CHILDREN *

Children are welcome to attend sessions with you. Please be aware they are under your responsibility at all times.

I understand and agree

This does not apply to me

CANCELLATION *

Please be aware that cancellation under 6 hours notice may incur a cancellation fee of up to $30

I understand and agree

DISCLAIMER *

I strongly recommend that before you undertake any activity on any premises, that you should first undergo a complete physical examination from a registered medical practitioner, to ensure that you are fit and able to commence your exercise program. You should advise your medical practitioner that the exercise program includes weightlifting, circuit training, aerobic and anaerobic exercise over prolonged periods of time. By signing this document, I acknowledge that engaging in physical activity may lead to serious or disabling injury, even death. I understand that all activities in any exercise program/session are optional, and I may stop at any time. I release my personal trainer (Jessica Trowbridge (nee Phillips)) and the business (Jessica Trowbridge Personal Training/JTPT) from any liability for any injury which I may suffer whilst participating in any activities howsoever otherwise caused. I have been advised and warned to obtain a wide-ranging and complete physical examination by a registered medical practitioner to confirm that I am fit and able to engage in all of the activities conducted on these premises. I acknowledge that I have read and understood all of the terms and conditions of this agreement prior to me signing the agreement and that the information it contains is true and correct. I assume with full knowledge the dangers in my participation in fitness activities and do so at my own risk. Where the applicant is a minor, this application and agreement must be signed by the minor and their guardian, who warrants and agrees by signing this agreement that he or she is authorised to enter into this agreement on behalf of the minor and remains responsible for the minor of all the terms and conditions set out herein, and indemnifies, the personal trainer form any claim by the minor.

I understand and agree