Juniors details, Parent / Guardians consent form

Juniors Name

First Name

Last Name

Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent / Guardian Email

Health Questionnaire -Does your child have or has she/he ever experienced any of the following? High or low blood pressure Elevated blood cholesterol Diabetes Chest pains brought on by physical exertion Epilepsy Dizziness or fainting Any bone, joint or muscular problems (e.g., hip, knee, back) Asthma or respiratory problems Any sustained injuries or illnesses Allergies Skin or other body surface problems that may be aggravated by the pressure of the hoop on the body (e.g., eczema, varicose veins) Recent wounds or surgery in the last 8 weeks

Health Questionnaire- Has your child ever been told that she/he should only do physical activity recommended by a doctor?

Health Questionnaire- Is your child on any medication?

if you have answered YES to any of the above health questions, please note details below and speak to a member of staff regarding this at the point of induction.

Parent / Guardians name

First Name

Last Name

Parent / Guardians DOB

YYYY

Parent / Guardians Phone number

(###)

###

####

As parent / guardian to the above named junior i agree to - Keep them within my eyesight at all times when attending the gym -Make sure they are using all the equipment responsibly and safely -Sign myself and my junior in and out of the gym using our membership numbers every time we attend -Attend a junior gym adduction with the above named junior -Ask a member of staff if myself or the junior need any help when attending the gym

i agree

i do not agree

Full responsibility - I named and signed below take FULL responsibility for the above named junior. and accept Vfitness is NOT liable for any injury / responsibility of the named above

I accept FULL responsibility

i do not accept this

Parent / Guardian Sign

Please Print your full name - followed by todays date to agree to all of the above