Forms BASIC INFORMATION Full Name(required) Date of Birth(required) Mobile Number(required) Home Number Email(required) Do you want to subscribe to email updates? Yes No Height(required) Weight (optional) Gender Male Female Other EMERGENCY CONTACT INFORMATION Emergency Contact(required) Who is this person to you?(required) Emergency Contact Number(required) Secondary Emergency Contact Number MEDICAL HISTORY History of heart problems? (Chest Pains, heart murmur or stroke)(required) Yes No Diabetes?(required) Yes No Asthma, breathing or lung problems?(required) Yes No Allergies?(required) Yes No Cancer?(required) Yes No Seisures, seizure medication,nuerological problems or dizziness?(required) Yes No High blood presure?(required) Yes No Recent surgery? (past 12 months)(required) Yes No Hernia or any condition that may be agrivated by exercise?(required) Yes No Previously recieved advice about exercise?(required) Yes No History of high colestorol?(required) Yes No Family history of corony heart desease?(required) Yes No Do you smoke tobacco products?(required) Yes No Do you consume excessive alcohol?(required) Yes No Do you take suppliments of any kind?(required) Yes No Are you on any medication?(required) Yes No Back problems, joint or muscle disorder still effecting you?(required) Yes No Do you have any skeletal injuries?(required) Yes No Excessive stress, depression anxiety or sleep disorder?(required) Yes No If you answered yes to any of the above, please consult your doctor by phone or in-person before you start your martial arts training. Tell your doctor about this medical questionnaire, which questions you answered yet too and get advice about how to moderate your exercise during training. Please provide us details of any of the above issues and any advice you've been given so that we can accommodate your needs. FITNESS LEVEL AND GOALS What are your fitness concerns or goals?(required) Weight loss Strength Power Endurance Cardio fitness Flexibility Agility Balance How long has it been since you have exercised regularly?(required) Do you participate in any other sports or physical training regularly?(required) Do you have any martial arts or self defence experience?(required) STATEMENT OF TRUTH I have truthfully filled out the personal information, medical history and fitness level and goals forms to the best of my knowledge at this current time.(required) Yes I understand CCMA is covered with public liability insurance and I will get student insurance, I will take every precaution necessary to maintain my own health and safety, taking advice from my doctor and instructor seriously.(required) Yes I understand that I have to follow instructions carefully, to exercise control whilst learning at a steady pace for my own and my training partners skill level and take care not to cause harm to other students.(required) Yes I understand that if I fail to inform my instructor of any health issues that may later cause me problems, or fail to follow advice from my doctor, that I am fully liable for the consequences.(required) Yes I fully understand the above statements and have consulted my instructor if I don't. I have ticked each statement box as they are true. Please type your full name to acknowledge this. Send
