Consent Form

Full Name*

Date of Birth*

Email Address*

Phone Number*

Emergency Contact Name*

Emergency Contact Phone Number*

Do you have a bone or joint problem which could be made worse by exercise?*

Yes
No

Have ever been diagnosed with any of the following:*

Heart disease?
High blood pressure?
Any other cardiovascular problems?
Diabetes?
Asthma?
Epilepsy?
None of the above?

Do you experience light-headedness or dizziness during physical exertion?*

Yes
No

Have you ever suffered from any of the following:*

Accountable chest pain?
Unaccountable chest pain?
None of the above

Are you or have you been pregnant in the last 3 months?*

Yes
No

I hereby state that I have read, understood and answered honestly the questions above*

Yes

I understand that it is my responsibility to inform DME Fitness if there any changes to my medical condition*

Yes

I have read and understood the disclaimer on the DME Fitness Live website page*

Yes

Type of Class*

Online
Face-to-Face

Covid-19
If you are attending our Face-to-Face Classes in the community you will need to complete this addition section on Covid-19, including our Track & Trace declaration below.

Address*

Have you been in contact with anyone displaying signs or symptoms of illness or Covid-19 in the past 14 days?*

Yes
No

Have you displayed any signs or symptoms of illness or Covid-19 in the past 14 days?*

Yes
No

Have you travelled outside of the UK or to any area with quarantine restrictions in the past 14 days?*

Yes
No

Track & Trace declaration*

By completing this document I state that I have been screened to take part in this exercise session, if I have answered YES to any questions I may be asked to seek medical advice before I can attend the class. I also agree to contact DME Fitness immediately and to register for the test, track and trace system should I become Covid-19 symptomatic or test positive for Covid-19 within 14-days of attending a Face-to-Face DME Fitness Class.

Yes

Any other comments?

Please Note: The information you provide on this Consent Form will only be used by DME Fitness and will not be shared with any other third-parties.

Name

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

Please complete all required fields

Covid-19

Ready to Make a Change?