Active Kids Agreement - Gym Services

ACTIVE KIDS PRESCREENING FORM

World Gym Burpengary | 159-161 Station Road, Burpengary Q 4505 | P 3053 3170

Active Kid's Name*

Date of Birth*

Gender*

Male
Female

Name of Parent/Guardian*

Parent/Guardian Contact Number*

Address*

Street Address

Is the guardian the emergency contact?*

Yes
No

Emergency Contact Name*

Emergency Contact Phone Number*

Relationship to 17 & Under Member*

Please note – in case of emergency, an ambulance may be used to transport your child to the nearest hospital or medical center.

BEHAVIOUR EXPECTATIONS*

I agree to the following:

We know kids can become excited in a whole new stimulating environment. This is why we have set some boundaries with clear concise rules and regulations. Our instructors will remind kids at the beginning of each class what’s expected. We have a (3) three-strike rule which applies to kids that continually disrupt or disrespect Instructors or other class participants. We’re all here to have fun, get fit and feel good.

Parent/guardian will be notified immediately in fairness to other kids. No refund will be given and in some cases the child may be banned from using our facility

If a child intentionally hurts another child, uses offensive language, damages equipment or any part of the World Gym facility, parent may be liable for any expenses incurred.

Parent or Guardian's Signature

PRE-SCREENING QUESTIONS

This screening tool does not provide advice on a particular matter, nor does it substitute 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 This tool is used 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

HEART - LUNG - OTHER SYSTEM

Has your child suffered from or have a HEART CONDITION?*

Yes
No

Please provide details:

Does your child have CYSTIC FIBROSIS?*

Yes
No

Please provide detail:

Does your child have DIABETES TYPE 1 OR TYPE 2?*

Yes
No

Please provide details:*

Does your child suffer from HIGH BLOOD PRESSURE?*

Yes
No

Please provide details:*

Does your child have HIGH CHOLESTEROL?*

Yes
No

Please provide details:*

Does your child suffer from ASTHMA?*

Yes
No

Please provide details:*

Does your child suffer from ANAPHYLAXIS?*

Yes
No

Please provide details:

OTHER*

Yes
No

Please provide details:*

SIGNS AND SYMPTOMS

Does your child experience, or has your child ever had:

1. Epilepsy, seizures or convulsions? If yes, is it at rest or during exercise?*

Yes
No

Please provide details:*

2. Fainting – if yes, please specify*

Yes
No

Please provide details:*

3. Dizzy spells – if yes, please specify*

Yes
No

Please provide details:*

4. Heat stroke/heart related illness – if yes, please specify if yes, please specify*

Yes
No

Please provide details:*

5. Increased bleeding tendencies/haemophilia? – if yes, please specify*

Yes
No

Please provide details:*

OTHER:*

Yes
No

Please provide details:*

7. Does your child have or had an eating disorder? – if yes, please specify.*

Yes
No

Please provide details:*

8. Does your child take medication? If yes, please specify.*

Yes
No

Please provide details:*

If your child is taking medication, please state any side effects experienced, as a result of taking this medication.

BONE/MUSCLE SYSTEM

In the last 6 months, has your child experienced any muscle pain during exercise?*

Yes
No

Please provide details:*

Please detail if a Doctor has treated this pain?

Has your child broken any bones or suffered any serious injuries in the last 12 months?*

Yes
No

Please provide details:*

BRAIN/ MUSCLE SYSTEM

Does your child have, or has your child had difficulty/problems with any of the following:

Vision
Hearing
Speech/Language
Motor sensory skills
Sleep apnoea

Please provide details:*

Has your child ever experienced a brain or spinal injury? Please specify.*

Yes
No

Please provide details:*

SPECIAL CONDITIONS

Does your child:

use a puffer or ventilator for asthma?
self-administer for diabetes?
have a chronic disability or chronic illness?
allergic to food, medication, pllens or any other allergens or specific environments?
follow a special diet?
been diagnosed with a nutritional deficiency?

Please provide details:*

GENERAL HEALTH

Does your child:

Has your child had any surgery in the last 12 months?
Are you aware of any medical condition/reason that may affect your childs ability to exercise in a program?
Other

Please provide details:*

I believe that to the best of my knowledge, all information I have supplied for my child within this tool is correct. If any information is to change regarding the above child I shall make a member of staff aware.

PARENTS OR LEGAL GUARDIANS OR GUARANTORS CONSENT

I/We UNDERSTAND THAT THESE PROVISIONS CONTAIN A COMPLETE AND UNCONDITIONAL WAIVER AND DISCLAIMER IN FAVOUR OF World Gym. I/We the undersigned being the Child’s parents or legal guardians or guarantors acknowledge reading the terms of this Agreement, and accept the terms and conditions herein. I/We understand that by signing below, I/We am/are waiving my/our right to sue World Gym if the Child suffers any injury, losses or damages of any nature whatsoever or even death. I/We also understand that, by signing below, I/We am/are agreeing to indemnify World Gym and I/We am/are taking full responsibility for any claims or damages that may be made against World Gym in respect to the Child’s use of the Equipment and/or engaging in the Exercises and/or simply being present at World Gym.

CONSENT

I hereby acknowledge that by signing: • The information provided above about my child’s health is to the best of my knowledge correct. • I will inform you immediately if there are any changes to the information provided above. • I give permission for my child to commence your training program.

Parent/Guardian's Signature*