Half Yearly Sign Up Form

Please fill out the form below, please note only offline payments are accepted e.g. Invoice, automatic direct debit, or bank transfer.

General Information

Title

Mrs

Miss

First name

Last name

Date of Birth

Address

Mobile

Prefer communication

Text

Both

Employer

Occupation

Terms and Conditions

Click HERE to view the terms and conditions

Upon signing this agreement, you herby agree to the terms and conditions detailed above.

Signature

Date of signature

Pre-Exercise Medcial Screening

Please indicate YES or NO for each question

CARDIOVASCULAR AND PULMONARY CONDITIONS

Diagnosed heart condition or stroke?

Yes

Diagnosed pulmonary disease?

Yes

Unreasonable chest pain during exercise?

Yes

Blood pressure over 140/90 or below 100/80?

Yes

HISTORY

Do you consistently feel faint or suffer from spells of dizziness?

Yes

Pregnant currently or in the last 12 months?

Yes

Do you have epilepsy?

Yes

Do you have arthritis?

Yes

Are you currently taking any blood pressure medication?

Yes

Do you suffer from asthma and require medication?

Yes

Currently or quit smoking/vaping within the last 6 months?

Yes

Any known bone or joint problems that could be aggravated by exercise?

Yes

Any known injuries?

Yes

Any conditions that may increase risk of adverse reaction to exercise?

Yes

If indicated yes to above question please specify.

Please indicate any medications you currently take. (If any)

Please specify any other medical conditions. (If any)

Your doctor (in case of medical emergency):

Emergency contact person

Name

Phone

INFORMED CONSENT

I acknowledge that the information provided above regarding my health and personal information is, to the best of my knowledge correct.

I will inform my exercise professional immediately if there are any changes in my health status.

I understand that participating in physical activity and exercise can carry a risk, and I accept all responsibility for that risk.

I understand that due care will always be undertaken by my exercise professional.

HSP Health and Safety Policy Statement

Click HERE to view the HSP health and safety policy statement

I acknowledge, understand and agree to adhere to the health and safety guidelines set forth by HSP.

Membership Option and Payment Method

Upfront

Bank TransferNZ$700

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Half Yearly Sign Up Form

General Information

Terms and Conditions

Pre-Exercise Medcial Screening

HSP Health and Safety Policy Statement

Membership Option and Payment Method

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