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Contact Details

Health Issues?

High Blood Pressure


Hip Replacement

Heart Problems



Carpal Tunnel Syndrome


If  you have any injuries, chronic illnesses or physical limitations not ticked above please provide details below.

If you have any back problems, please provide details below

If pregnant, how many months?

If new mother how many months?

I have enrolled in a class that involves strenuous physical activity.   I am aware that such activities can cause injury or physical harm.  Notwithstanding this knowledge, I have decided to enrol in this program and by doing so, I knowingly and voluntarily assume all the risk inherent in such a program.  I do not hold the instructor liable for any damages arising from personal injuries sustained while participating in any classes.

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