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Screening
Jason McGee
2021-07-14T17:00:42+01:00
Thank for for joining up to Felda
Please complete the new members screening form below :-
New Member Screening/GDPR Form
FELDA HEALTH, FITNESS AND SPA SCREENING FORM
The information contained in this form is totally confidential and is only used to plan a safe and effective training program for you.
Name
*
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Mr/Mrs/Miss
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
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Cook Islands
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Iran
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Ireland
Isle of Man
Israel
Italy
Jamaica
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Jersey
Jordan
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Kenya
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Lebanon
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Virgin Islands, U.S.
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Country
Phone
*
Date Of Birth
*
Day
Month
Year
Email
*
Medical Contacts
Emergency Contact Name
*
Emergency Contact Number
*
Doctor Name
*
Doctor Number
*
Medical Conditions
Please answer the following questions by circling the appropriate response: Do you suffer/have ever suffered from any of the following conditions?
Heart Disease / Chest Pain when exercising
*
YES
NO
High or low blood pressure
*
YES
NO
History of heart disease or stroke in your family (before 55 yrs)
*
YES
NO
Asthma or Lung Problems
*
YES
NO
Diabetes
*
YES
NO
Thyroid Condition
*
YES
NO
Epilepsy
*
YES
NO
Hernia
*
YES
NO
Are you currently on any type of medication
*
YES
NO
Muscle Joint or Back Pain
*
YES
NO
Are you / have you been pregnant in the last 6 months
*
YES
NO
Have you had any surgery in the last 6 months
*
YES
NO
Have you been advised by a doctor not to exercise
*
YES
NO
Do you have any other conditions which may limit your exercise
*
YES
NO
Please provide details
*
Do you smoke
*
If so - how many per day
Do you exercise regularly
*
If so - please provide details
Have you had a cholesterol test
*
If so - please provide details
More Information
If you answer “Yes” to any of the above please explain your condition
Customer Agreement
*
I intend to use facilities/ take part in the exercise program, assessment/ class offered by Felda Health, Fitness and Spa. I am aware that as with all types of exercise there is an inherent risk of heart attack, death, light headedness, fainting, cramps, muscle or joint injury etc. I understand the risks and know that I am free to withdraw from the exercise or modify my activity levels at any time. I assume full responsibility during and after my participation to use or apply at my own risk any portion of the information or instruction I receive. I understand that Felda Health, Fitness and Spa accepts no responsibility whatsoever for any injuries or death during or after participation in the program, assessments/exercise classes. I have read, understood and agree the contents of this informed consent agreement in its entirety.
YES
NO
Membership Agreement - Details
Membership Term
*
Select ...
Direct Debit
3 Month
6 Month
12 Month
Other
Payment Method
*
How did you pay
Terms Of Membership
*
I hereby agree that I will use the facilities of Felda Health, Fitness and Spa at my own risk and that Felda have no liability whatsoever, whether in tort or in contract, for any loss, injury or damage whatsoever sustained by me. I accept full responsibility for my use of any and all facilities, appliances, privilege or service and hold harmless Felda Health, Fitness and Spa, its employees, representatives, agents or lessors, from any and all loss, claim injury, damage or liability sustained or incurred by me or my property, howsoever caused.
YES
NO
Marketing and GDPR
How did you hear about Felda?
*
Website, Social Media, Email, Print, Radio, Word Or Mouth, etc
Marketing Consent
*
Email Marketing - Promotions, Newsletters
Text Marketing - Renewal Reminders, Membership Status, Promotions & Motivations
No Marketing - Opt back in at any time
Felda Privacy Policy - https://felda.ie/privacy-policy
*
I have read and understood this policy
YES
NO
Official Use Only
Email
This field is for validation purposes and should be left unchanged.
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