Back Burpengary - College of FitnessADULT PRE-EXERCISE SCREENING TOOLName* Date of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender* Male Female Mobile* Email* This screening tool does not provide advice on a particular matter, nor does it subsitute for advice from an appropriately qualified Medical Professional. No warranty of safety should result from its use. The screening system in no way guarantees against injury or death. No responsibility or liability whatsoever can be accepted by World Gym, Exercise and Sports Science Australia, Fitness Australia or Sports Medicine Australia for any loss, damage or injury that may arise from any person acting on any statement or information contained in this tool.STAGE 1 AIM: To identify those individuals with a known disease, or signs or symptoms of disease, who may be at a higher risk of an adverse event during physical activity/exercise. This stage is self administered and self evaluated.1. Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?* Yes No 2. Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?* Yes No 3. Do you ever feel faint or have spells of dizziness during physical activity/exercise that cause you to lose balance?* Yes No 4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?* Yes No 5. If you have diabetes (type I or type II) have you had trouble controlling your blood glucose for the last 3 months?* Yes No 6. Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?* Yes No 7. Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?* Yes No IF YOU ANSWERED ''YES'' to any of the 7 questions, please seek guidance from your GP or appropriate allied professional prior to undertaking physical activity/exercise IF YOU ANSWERED ''NO'' to all the 7 questions, and you have no other concerns about your health, you may proceed to undertake light-moderate intensity physical activity/exercise.Signature: I believe that to the best of my knowledge, all of the information on the Pre-Screening that I have supplied within this tool is correct. I hereby agree to abide by the above rules and regulations and report any undesireable behaviour or breachs to the above.World Gym Burpengary Rules and RegulationsConsent* I agree to the following rules and regulations:These Rules and Regulations are in place to ensure that we protect the rights of the members and ensure that you can achieve your results in a pleasant, motivating and non judgemental environment. • COVID – All members are to keep to 1.5mtrs physical diistancing. • COVID – Practice good hand hygiene, clean and disinfect your environment. • COVID – Members are to stay at home if you unwell and / or have any symptoms of the virus. • Members MUST sign in with their key tag on arrival • Members must wear covered foot wear and clean respectable, gym attire. At the discretion of World Gym Management. Jeans or clothes which can tear upholstery NOT allowed. No dirty workwear allowed. • Bags NOT permitted on gym floor. • Towels must be used at all times when using equipment and stretch area. • Sexual or racial harassment or harassment or intimidation of any kind will not be acceptable. • Profanity, excessive noise, excessive grunting or yelling will not be acceptable. • Theft or Drug Dealing of any kind will be reported to the police. • Dropping of weights and banging machines is not allowed. Treat equipment with respect otherwise membership can be terminated. • It is a requirement of your membership and a courtesy to others that all weights, plates, dumbbells, barbells and other equipment used, shall be returned to its rack, stand or place of origin after use. • All members must respect the staff and other members, and be courteous of their rights and privileges while in the facility. • Entering the facility under the influence of alcohol or drugs is strictly prohibited. • Partaking in any illegal action or activity within the World Gym Boundaries including the car park is strictly prohibited. • Spitting, vandalism or unruly behaviour will not be permitted. • You are NOT permitted to bring any non-members into the Club during unstaffed hours, or let anyone else use your 24/7 keytag at any time otherwise fines and cancellation of membership will apply. • Only World Gym licensed personal trainers are permitted to train or coach members within the Club. Anyone found doing this will be asked to leave gym immediately. • Pin coded lockers in change rooms are only to be used for the duration of your training session. Every night the lockers will be cleaned out and items thrown away. • Smoking including e-cigarettes is strickly prohibited in all areas of the gym. • Certain areas will be locked and unaccessible during unstaffed hours. These include -Sauna, Steamroom & Monsoon Shower (Relaxation Area). -Supplement Shop & Café and behind reception or any staff only area. • Selling of supplements, foods, drinks, merchandise products by any members or staff not approved by Club Manager on World Gym Burpengary Property is strictly prohibited. • Children or members under the age of 16 cannot use Club during unstaffed hours and they must be accompanied by an adult during normal staffed hours. All children who are not members of the gym must be admitted into Kidsworld upon entry. • Members are solely responsible for their own belongings while training at World Gym Burpengary. Burpengary Gym Pty Ltd accepts no responsibility for any loss or damaged personal property. • Report any broken or damaged equipment to staff at reception. Consent* With regard to MMA Cage the following rules apply –a) Protective equipment such as mouthgaurds, gloves, and headgear MUST be worn. b) No fighting or light sparring within the MMA Cage. c) Absolutely NO Shoes to be worn inside MMA Cage. d) In an effort to keep it fair for all members a maximum time limit of 30 minutes at a time applies to use of MMA Cage. e) Please wipe down floor after use. Consent* With regard to World Gym Athletics Membership the following rules apply• Access to the World Gym Athletics Zone is available to members ONLY, 24 hours a day. If unauthorized members are taken into the zone, the members will be charged $20.00 on their next payment. • During unstaffed hours, safety pendants are accessible for use. We advise to use the pendants at anytime when training in this zone outside of classes times. • Access for training to this zone is available up until 30 minutes prior to a schedule class. • The zone is unavailable for generic training during World Gym Athletics Classes • No equipment is to be removed from the World Gym Athletics Zone GLOBAL FITNESS COLLEGE• I am aware Global Fitness College is a third-party RTO to The College of Health & Fitness? • I understand upon completion and competency, my certificate will be issued by The College of Health and Fitness? • I have not been offered incentives by Global Fitness College and understand that completing this course does not entitle or promise a job once completed? • I understand the duration of the course is 12 months? • I understand what is required of me to complete the course and how I will be assessed? • I understand payment options, terms and conditions? • I understand what study support are available during the 12 months as a student of Global Fitness College? • I understand I am entitled to receive all necessary learning resources? • I understand I will be provided with helpful feedback to help me complete the course?* I acknowledge the following:• I am aware Global Fitness College is a third-party RTO to The College of Health & Fitness? • I understand upon completion and competency, my certificate will be issued by The College of Health and Fitness? • I have not been offered incentives by Global Fitness College and understand that completing this course does not entitle or promise a job once completed? • I understand the duration of the course is 12 months? • I understand what is required of me to complete the course and how I will be assessed? • I understand payment options, terms and conditions? • I understand what study support are available during the 12 months as a student of Global Fitness College? • I understand I am entitled to receive all necessary learning resources? • I understand I will be provided with helpful feedback to help me complete the course?SignaturePrinted First and Last Name* World Gym Burpengary | 159-161 Station Road, Burpengary Q 4505 | P 3053 3170 | E: reception@worldgymburpengary.com.au