Pre Activity Questionnaire & Waiver Name * First Name Last Name Date of Birth * MM DD YYYY Phone * (###) ### #### Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact Name * Emergency Contact Phone * (###) ### #### Please tick any of the following that apply to you * Pelvic Organ Prolapse (POP) Any pelvic floor symptoms such as leaking, pain, heaviness, bulging or dragging, low back pain Fainting Dizziness Low BP High BP Stroke Diabetes Heart Condition Asthma Anxiety/panic attacks Blood clots Circulation problems Are there any other limitations, or medical accommodations you need, or would like to share with me about? If you are dealing with pelvic organ prolapse or other symptoms of pelvic floor dysfunction I highly recommend seeing a pelvic floor physical therapist. I also strongly recommend that before you undertake any activity on any premises, that you should first undergo a wide-ranging and 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 breathwork, stretching, mobility training and bodyweight strength training for prolonged periods of time. PRIVACY STATEMENT AND ACKNOWLEDGEMENT * Please note: In this privacy statement and acknowledgment you acknowledge that you will in completing this acknowledgment, disclose to me, Zoe Wood, information about you including information in relation to your health. I agree that I will deal with that information in accordance with the privacy principles set out below and with the Privacy Act 1988. TERMS AND CONDITIONS * 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 are optional, and I may stop at any time. I release Zoe Wood 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 his or her guardian, who warrants and agrees by signing this agreement that he or she is authorized 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. Date * MM DD YYYY One last thing - what's one thing you'd like to learn or take away from the workshop? Thanks so much! I’m looking forward to seeing you at the workshop, Zoe Thanks so much! I’m looking forward to seeing you at the workshop! Zoe
