Name *

First Name

Last Name

Phone *

(###)

###

####

Next of Kin *

First Name

Last Name

Next of Kin Phone Number *

(###)

###

####

Date of Birth *

Month / Day / Year

MM

DD

YYYY

Are you Pregnant? *

Yes

No

Have you been pregnant in the last 4 months? *

Yes

No

Do you have any heart problems? *

Yes

No

Do you have any back issues? *

Yes

No

Do you have epilepsy? *

Yes

No

Do you have any joint problems? *

Yes

No

Do you have asthma? *

Yes

No

Do you have diabetes? *

Yes

No

Have you any medical conditions? *

Yes

No

Are you taking any medication? *

Yes

No

I declare that to the best of my knowledge the information given above is correct and that I am unaware of any reason why I should not participate in any form of physical activity. I agree that it is my decision to enter into exercise entirely at my own risk and I waive any legal recourse for damages to myself which may arise from my participation in physical activity.

Yes

No

I have been made fully aware that I am entitled to a full induction to all the equipment and facilities here in Osprey Leisure Club. If I choose to not receive my induction I am accepting all responsibility for my actions while on this premises and using the facility. I hereby acknowledge and agree that I will enjoy the facilities provided within Osprey Leisure Club entirely at my own risk and that I will not hold or endeavour to hold Osprey Leisure Club its servants, agents, offices, employees or representatives for any injury, loss, damage or expense incurred by me or on my behalf or suffered by me or on my behalf arising out of the use of the enjoyment and use of the facilities of said club, howsoever arising.I hereby acknowledge that it is my personal responsibility to disclose any known medical conditions or injuries to a member of staff prior to using the facilities and I fully understand the effect and the importance of this disclosure.

I would like to book in for an induction

I would not like to book in for an induction