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Member Details

* indicates a required field

First Name*

Last Name*

Date of Birth*

Age*

Gender*
FemaleMaleOther

Street Address*

Suburb*

State*
ACTNSWNTQLDSATASVICWA

Postcode*

Mobile*

Home Phone

Business Phone

Email*

Employer

Occupation

I acknowledge that any partial installments allowed by management must be paid in full as and when due, even if I fail to attend McQuinn’s Gym Bendigo and take part in the service offered.
Release and Indemnity to McQuinn’s Gym Bendigo:
In consideration of being permitted to enter the Gym and, where applicable, the acceptance of my membership payment:
• I enter the Gym at my own risk.
• I participate in the activities at my sole risk and responsibility.
• I release, indemnify and hold harmless McQuinn’s Gym Bendigo, its servants, staff and agents from and against all and any actions or claims which may be made by me or by other parties acting on my behalf, for or in respect of or arising out of any injury, loss, damage or death caused to me or my property whether by negligence, breach of contract or in any way whatsoever.
• I release, indemnify and hold harmless McQuinn’s Gym Bendigo, its servants, staff and agents from and against all and any actions or claims which may be made against me arising out of any injury, loss, damage or death to or of another patron of the Gym which is allegedly caused by me whether by negligence, breach of contract or in any way whatsoever.

I also agree that in the event that I am injured or my property is lost, damaged or stolen I will bring no claim, legal or otherwise against McQuinn’s Gym Bendigo, its servants, staff or agents, in respect of that injury, loss or damage.
Before signing this document I confirm that I have read and fully understand it and know how it affects my legal rights.
This release and indemnity is a continuing release and indemnity and shall apply to and be effective in respect of any future membership and/or attendance by me at the Gym.

*I agree to the above terms and conditions.

Health Evaluation

Please answer the following questions truthfully, there are no wrong or right answers, this will help to create a program that is best suited to your individual needs and prevent any injuries or contraindications.

1. Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?*
YesNo

2. Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?*
YesNo

3. Do you ever feel faint, dizzy or lose balance during physical activity/exercise?*
YesNo

4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?*
YesNo

5. If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months?*
YesNo

6. Do you have any other conditions that may require special consideration for you to exercise?*
YesNo

7. Do you take any prescribed medication/s?*
YesNo

7a. If Yes, please list

8. Have you had any major surgery during the last 12 months?*
YesNo

8a. If Yes, describe

9. Are you pregnant or have you given birth within the last 12 months?*
YesNo

9a. If Yes, provide details

10. Do you have, or have you ever, suffered from any of the following: (Tick all that apply)*
AsthmaArthritis or Joint PainDiabetesDifficulty BreathingHigh Blood PressureHigh CholesterolHerniaLow Blood PressureVaricose Veins

11. Any other conditions, or injuries(current or previous)?*
YesNo

11a. If Yes, describe

Fitness Information

12. Do you want a training program written up?*
YesNo

If you answered YES to the above question, please fill out the questions below, otherwise skip to the Signature section.

13. How do you rate your current fitness?
Very LowLowGoodVery Good

14. Are you currently engaged in physical exercise?
YesNo

14a. If Yes, describe

14b. Frequency and Duration

15. If you are not currently exercising, have you ever engaged in physical exercise?
YesNo

15a. If Yes, describe

15b. Frequency and Duration

16. What is your main goal?

17. How main days a week do you want to train?

18. Are there any body parts you want to focus on?

19. Are there any body parts you don't want to focus on?

I declare that all the information I have supplied above is true and correct to the best of my knowledge, as of

Signature: