SECTION 1 | PERSONAL INFORMATION
Name
*
First Name
Last Name
DOB
*
MM
DD
YYYY
Age
*
Are you Over or Under 18 ?
*
Yes, I am 18 or older
No, I am Under 18 and my legal gardina continues the form below
Still Unsure
Full Name of Legal Gardian
First Name
Last Name
Participant phone
*
(###)
###
####
Participant email
*
Participant Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Legal Guardian phone
if applicable
(###)
###
####
Emergency Contact Name
*
Emergency Contact Phone
*
SECTION 2 | PHYSICAL ASSESSMENT
Have you ever participated in group exercise or used a gym in the past ? Please give brief exercise and physical activity history
*
Please rate your perceived physical fitness level using a scale of 1-10, 1 being low and 10 high
*
1
2
3
4
5
6
7
8
9
10
Do you participate in regular physical activity ?
*
if yes please give details
SECTION 3 | MEDICAL ASSESSMENT
Have you ever had any medical conditon, injury, illness, back or joint pain, or muscular pai that may be aggravated by vigourous exercise ?
*
YES or NO and provide details if YES
Have you ever had Arthritis, Astham, Diabes, Epilepsy, Hernia, Ulcer of Dizziness of any kind ?
*
YES or NO and provide details if YES
Have you ever had Arthritis, Astham, Diabes, Epilepsy, Hernia, Ulcer of Dizziness of any kind ?
*
YES or NO and provide details if YES
Do any of your immediate family below the age of 60 have a heart condition, high blood pressure, stroke, high cholesterol or chest pains?
*
YES or NO and provide details if YES
Are you currently taking any prescribed medication?
*
YES or NO and provide details if YES
Do you currently or have you in the past smoked?
*
YES or NO and provide details if YES
Are you subject to any other medication, physical and or mental condition that may negatively influence your ability to participate safely in prolonged physical activity?
*
YES or NO and provide details if YES
Do you currently or have you in the past smoked?
*
YES or NO and provide details if YES
HIKOI KI TE HAUROA —THE JOURNEY TO WELLBEING
He nui nga mihi kia koutou katoa! Welcome to “The Whare Hauora”
Thank you for taking the first steps in your journey to Well Being. As you will be using our facility there are a few things we would like you to be aware of:
RELEASE
Photo and Media Consent
I consent to having photos or videos of me (or my child if under 18) taken during classes or sparring and shared on social media platforms, The Refinery’s website, or any publications related to the dojo
Acknowledgement and Consent
*
By submitting this form, I, the participant (or the legal guardian if the participant is under 18), fully understand and agree to the terms and conditions outlined, including the acceptance of any risks associated with martial arts training, and I confirm that the information provided is accurate to the best of my knowledge.
Thank you! Your registration has been successfully submitted. We look forward to welcoming you (or your child) to The Refinery. You will receive a confirmation email shortly with further details. If you have any questions, feel free to contact us!
