Documenti di Didattica
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Photo:
Staff Sign
Surname: Title: Male: Female: Full Address: Tel Home: Mobile: Emergency Contact:
1. Has your Doctor ever said that you have a heart condition and that you should only do physical activity recommended by a Doctor? Yes No 2. Do you ever feel pain in your chest when you do physical exercise? Yes No 3. Have you ever had chest pain when you were not doing physical exercise? Yes No 4. Do you ever feel faint or have dizziness? Yes No 5. Do you have a joint problem that could be made worse by exercise? Yes No 6. Have you ever been told you have high blood pressure? Yes No
7. Are you currently taking any medication of which the instructor / teacher should be made aware of? If so what?
Yes
No Notes:
8. Are you pregnant or have you had a baby in the last 6 months? Yes No 9. Do you have breathing problems? Yes No 10. Do you have any skin infections or open wounds? Yes No 11. Is there any other reason why you should not participate in physical activity? If so what? Yes No Notes:
Yes to one or more question from 1 -11: Talk to your Doctor before you start taking physical
exercise and before you complete your fitness induction. You may well be able to do any activity you want, as long as you start slowly and build up gradually. Or you may need to restrict your activities to those which are safe for you. Talk to your Doctor about the kinds of activities you wish to participate in and follow their advice.
No to all questions: You can be reasonably sure that you can start taking exercise. Begin slowly
and build up gradually. However, postpone your induction if you have a temporary illness. If you think you may be pregnant, talk to your Doctor before you start an exercise program.
Referred to Doctor
Staff Sign
Irish White : British Black : Black British African Mixed White & Black Caribbean White & Black African Asian: Asian British Indian Bangladeshi Pakistani Other ethnic group: (please specify)
Do you consider yourself to have a long standing illness, disability or infirmity which limits your daily or work in any way? Yes (see below) No If so, please tick disability type: Visual Impairment Learning Disability
Induction Status - Gym equipment may vary between gyms you have used before.
I have had an induction I have not had an induction and would like to book one I have been offered an induction but decline this offer at my own risk. Staff Sign___________________ Data Protection Act 1998
Sport@Kenton follows the guidelines set out below. Kenton School will use the information you provide for the purpose of Leisure Centre administration. We would like to be able to send you information on our services. Our partner organizations would also like to send you information about their services. If you are happy for us to do this please tick the appropriate box.
Sport@Kenton Yes No Partner organisations Yes No If you have any questions concerning date protection you can contact: Kenton School HR Officer on 0191 2142200 or by e-mail at admin@kenton.newcastle.sch.uk Formal Declaration I declare to the best of my knowledge I know of no reason why I should not participate in exercise. I take part in any form of exercise entirely at my own risk and waiver any legal recourse for damage to myself or property arising from my participation. Signed Office Use Initial Fee: Linked Membership: Name Dated Monthly Fee: Membership No:
SO / Card / Cash
Date:
Date: Date:
All users must sign a copy of this form along with a copy of IPQ Form. Both forms to be kept on site for reference at any time.