{titlefromplan}


 

Title
  • - select your title -
  • Mr.
  • Mrs.
  • Miss.
  • Ms.
  • Dr.
- select your title -
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First Name
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Last Name
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Preferred Name:
(Shortened first name or nickname etc.)
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Address:
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Town / City:
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County:
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Postcode:
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Mobile :
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Sex:
  • - select a option -
  • M
  • F
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Occupation:
Your job?
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Date of Birth:
Select a date
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E-mail address:
Your E-mail Address
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Please select Yes/No. If anything changes at a later date you MUST inform us
Do you have pins, plates, bolts or a heart pace-maker fitted to you?
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Explain here...
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Do you have, or have you ever had, heart or lung problems?
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Explain here...
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Do you have, or have you ever had, blood pressure problems (high or low)?
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Explain here...
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Are you currently using any form of medication or drugs that will affect your ability to use the gym?
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Explain here...
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Do you suffer pain or swelling in any joints - including back problems?
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Explain here...
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Do you suffer from epilepsy, asthma, diabetes, problems with excessive sweating?
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Explain here...
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Do you suffer from dizzy spells, fainting, bad migraines or severe allergies?
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Explain here...
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Are you recovering from any accident, illness or operation? (Less than 12 months ago)
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Explain here...
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Are you pregnant?
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You’re male but you ticked Yes! We may have to contact The Guinness Book of World Records!

Have you ever been advised to refrain from exercise, dieting, sunbed or sauna use?
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Explain here...
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Have you ever had an allergic reaction to sauna use, the sun or sunbed tanning?
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Explain here...
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Are there any other details which may affect you using the facilities at DLC?
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Explain here...
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Emergency Contact Name:
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Emergency Contact Number:
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What's Your Goal:
You may select more than one
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Have you ever used a Gym etc before?
Gym:
  • - select a option -
  • Yes
  • No
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Classes:
  • - select a option -
  • Yes
  • No
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How did you hear of us?
  • - select a option -
  • Friend / Family
  • Internet / Media
  • Newspaper
  • Leaflet
  • Signs
  • Radio
  • Ex-Member
  • Other
- select a option -
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Declaration: I declare that the information given on this form is, to the best of my knowledge, accurate and true. Unless stated otherwise on this form, there is no reason I know of why I shouldn’t use a sunbed or undertake any type of exercise or restrictive diet. I understand that I participate in all exercise sessions, classes, treatments or sunbed sessions entirely at my own risk. I will adhere to instructions & guidelines given to me & posted in the building. I am fully aware of the importance of consulting a doctor before commencing any exercise, restrictive diet, treatment or sunbed sessions.
By clicking the Submit button below, you acknowledge you’ve read, understood and agree to this declaration and our Terms & Conditions.

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