test - form - Arthritis & Osteoporosis Tasmania

This field is hidden when viewing the form

Class:*

Email*

Preferred phone number*

Age (in years)*

Please enter a number from 18 to 100.

Type of arthritis

This field is hidden when viewing the form

Program Notes

Would you like to sign-up to our eNews?*

This field is hidden when viewing the form

Week 1

This field is hidden when viewing the form

Week 2

This field is hidden when viewing the form

Week 3

This field is hidden when viewing the form

Week 4

This field is hidden when viewing the form

Week 5

This field is hidden when viewing the form

Week 6

This field is hidden when viewing the form

Week 7

This field is hidden when viewing the form

Week 8

This field is hidden when viewing the form

Week 9

This field is hidden when viewing the form

Week 10

Participant Policy

Medical Clearance

This field is hidden when viewing the form

As you answered Yes, please give more information on the nature of your condition and when it was first diagnosed

As you answered Yes, has this occurred in the last 1-3months and are you aware of the (potential) cause or condition that may be attributed to this experience (e.g. diabetes, cardiorespiratory disorder or other)?*

As you answered Yes, do you require any medication to assist you during exercise (e.g. ventilator, reliever etc)

This field is hidden when viewing the form

As you answered Yes, please provide a brief but detailed summary of your recognised special consideration (e.g. time of event, nature and whether it is resolved or ongoing)

7. Please reflect on your health during the current periods, and note any health developments (e.g., injuries, condition diagnoses) that you think may be relevant to your participation in our exercise (Note: if no major/significant issues have arisen please write No)

Last 6 months:

Last 12 months:

Last 3 years:

8. Describe your current physical activity/exercise levels in a typical week by stating the frequency and duration at the different intensities. For intensity guidelines download the Exercise Intensity Guide.

Total minutes per week

Total Minutes = (frequency x duration)

As you entered Yes, please provide more detail*

Arthritis TAS Exercise Participation Waiver

READ CAREFULLY BEFORE SIGNING

In consideration for my participation in “The program” hosted by Arthritis TAS. I hereby RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE, AND AGREE TO INDEMNIFY AND HOLD HARMLESS for any and all purposes SPONSOR, Arthritis TAS and their respective officers, servants, agents, volunteers, or employees (herein collectively referred to as RELEASEES) FROM ANY AND ALL LIABILITIES, RESPONSIBILITIES, CLAIMS, DEMANDS, CAUSES OF ACTION OR INJURY, INCLUDING DEATH, that I may sustain or to any property belonging to me whether caused by the negligence of the RELEASEES or otherwise, while participating in the Program, or while in, on or upon the premises where the Program is being conducted.

Consent Date*

Payment

This field is hidden when viewing the form

Sign up date*

This field is hidden when viewing the form

Billing Date*

This field is hidden when viewing the form

Days Counter*

Strength & Balance

Price:

The price is pro-rata so if you join during the term, the price will be calculated automatically. Please note: If you register on the day of the class, you will join the class the following week.

Credit voucher code:

Total

Credit Card*

Email

This field is for validation purposes and should be left unchanged.

test – form

Registration: SBP: Monday: 10am

Participant Policy

Medical Clearance

Arthritis TAS Exercise Participation Waiver

Payment