Back "*" indicates required fields CHARITY TRIATHALON - WORLD GYM BUNDABERGADULT PRE-EXERCISE SCREENING TOOLTodays Date DD slash MM slash YYYY Name* First Last Mobile* Email* Medical WaiveThis 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 If yes - please describe:*2. Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?* Yes No If yes - please describe:*3. Do you ever feel faint or have spells of dizziness during physical activity/exercise that cause you to lose balance?* Yes No If yes - please describe:*4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?* Yes No If yes - please describe:*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 If yes - please describe:*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 If yes - please describe:*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 yes - please describe:*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.World Gym Bundaberg 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 distancing when directed. • 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 strictly 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), Rock Climbing Wall , Pool, 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 Bundaberg 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 Bundaberg. Phoenix Health Clubs 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 Boxing Ring the following rules apply –a) Protective equipment such as mouthgaurds, 16 oz gloves, and headgear MUST be worn, and an authorised boxing coach must be present for sparring sessions. b) Absolutely NO work shoes to be worn inside the Boxing Ring. c) No use of boxing ring while scheduled classes are on. d) Please wipe down floor after use. e) No use of boxing ring outside of staffed hours which are ; Mon- Thurs - 5 am - 8 pm Friday - 5 am - 6.30 pm Saturday - 7 am - 4 pm Sunday - 8 am - 4 pm f) No horseplay or misusing boxing ring or boxing equipment. Pool consent* By checking the box I hereby acknowledge that, at times, the pool area at World Gym Bundaberg may be unsupervised and I accept full responsibility for my own actions during these times. a) No use of pool outside of staffed hours which are ; Monday - Thursday - 5 am - 9 pm Friday - 5 am - 6.30 pm Saturday - 7 am - 4 pm Sunday - 7 am - 4 pm b) You MUST see reception to request to unlock pool prior to your swim. c) No horseplay or running around in the pool area. d) 17 and Under Members or guests are not permitted in pool area without adult supervison. e) All bathers , before entering the swimming pool shall be required to take a cleansing shower. f) Consumption of food and beverages and the use of tobacco products including e-cigarettes shall not be permitted in the swimming area. g) Any person suspected of being under the influence of drugs or alcohol shall be prohibited from entering the pool. h) No children shall be allowed access to pool area without adult supervison. j) Swim diapers are required for all children that are not toilet trained. This World Gym location is a licence of World Gym International, Inc and is independently owned and operated. FITNESS REPRESENTATION: ASSUMPTION OF RISK; RELEASE AND LIABILTY WAIVER; INDEMNIFICATION OF WORLD GYM THIS IS A LEGALLY BINDING WAIVER, RELEASE AND INDEMNIFICATION. PLEASE READ IT CAREFULLY BEFORE SIGNING.* I agree to the following:In considering for my use of World Gym facilities, I hereby stipulate and agree as follows: I realise and accept the risks of cardiovascular exercise, weight lifting, weight training and/or body building, and I am fully aware of the possibility of mechanical and/or other malfunctions of cardiovascular equipment, weight machines, and/or apparatus (“equipment”) due to the negligence of World Gym or otherwise, as well as the possibility of injury to me as a result of my or others’ use of such cardiovascular equipment, weight machines, and/or weight machines and apparatus. I fully understand and accept the serious consequences which might result due to my involvement in cardiovascular exercise and weight training and/or body building while at World Gym premises. Based on that understanding, I voluntarily assume any and all risk of, and hereby fully, unconditionally and forever release World Gym, its franchiser/licensor, and all of World Gym employees, owners, shareholders, directors, agents, independent contractors and affiliates from any loss, damage, injury or claims of any kind whatsoever that relate to my or others’ use of any and all of the equipment and facilities of World Gym. I represent and warrant that I am in physically sound condition and I have no disability or impairment that would prevent me from engaging in active or passive exercise that would be detrimental to my health, safety or physical condition. I am in good health and have no physical conditions that would be aggravated by my involvement in cardiovascular exercise, weight lifting, weight training and/or body building, nor do I have any physical limitations that would procure such involvement. I have medical approval to proceed with a normal routine of exercise, and all exercises shall be undertaken by me at my sole risk. I understand and agree that World Gym is not responsible for evaluating my physical condition and will not undertake to do so. I understand that World Gym will not provide or pay for medical and/or hospitalisation care or insurance for my benefit in the event of any injury to me occurring as a result of my being on any portion of the premises of World Gym. I will abide by the World Gym Rules and Regulations, as they may be changed or updated from time to time in World Gym’s sole discretion. I will comply with all Rules and Regulations regarding my guests, and I will cause my guests to comply with all Rules and Regulations at any time, World Gym shall have the right, in it’s sole and absolute discretion at any time, to cancel my membership, and in such event I will not be entitled to a refund for any prepaid membership fees that would have been accrued for the rest of the term. In attending World Gym and using its facilities and equipment, I agree that I am doing so at my own risk. I understand that it is not World Gym’s responsibility to supervise my or others’ use of the equipment or facilities or conduct within or around the premises, and I understand and agree that World Gym shall not be liable or responsible for any personal injuries (including death) or property loss, theft or damage I sustain on or around the premises of World Gym, whether or not World Gym is alleged to be negligent. I hereby assume all responsibility for any personal injuries (including death), property loss, or property damage that I may suffer, or that I or any of my guests cause others to suffer, in connection with my, or my guest’s, use of the equipment or facilities of World Gym or my presence within or around the premises of World Gym. With Full knowledge of the consequences, i.e., that I am waiving my right to sue, I voluntarily and expressly waive and agree to unconditionally, fully and forever release World Gym and all of its employees, owners, shareholders, directors, agents, independent contractors, affiliates, successors and assigns, and its franchiser/licensor, from all liability or claims for, or relating to, any personal injury (including death), property loss, theft or property damage, tortious acts or omissions, unlawful acts or omissions, or other claims of whatever nature sustained or asserted by me in connection with my, or others’ use of World Gym equipment or facilities or my or others’ presence or conduct on or around the premises of World Gym, and not withstanding the negligence or alleged negligence of World Gym. This release and waiver will survive my termination of membership. I also assume full responsibility for, and agree to indemnify, defend and hold harmless World Gym and all of its employees, owners, shareholders, directors, agents, independent contractors, affiliates, successors and assigns, and its franchiser/licensor (collectively, “World Gym”), against any claims, damages, liability or expenses (including reasonable legal fees) for, any personal injury (including death), property loss, theft or damage, tortious acts or omissions, or other claims of whatever nature asserted by any other person or entity against World Gym in connection with my, or my guest’, use of the World Gym equipment or facilities or my, or my guests’, presence or conduct on or around the premises of World Gym , and notwithstanding the negligence or alleged negligence of World Gym. This indemnification will survive the termination of my membership. I acknowledge and intend that this release and waiver of rights shall be affective not only on the date hereof, but also on all occasions subsequent hereto. I UNDERSTAND THAT THESE PROVISIONS CONTAIN A COMPLETE AND UNCONDITIONAL WAIVER AND DISCLAIMER IN FAVOUR OF WORLD GYM. I understand that by signing below, I am waiving my right to sue World Gym (as defined above) if I suffer any injury, losses or damages of any nature whatsoever. I also understand that, by signing below, I am agreeing to indemnify World Gym and I am taking full responsibility for any claims or damages that may be made against World Gym by any other person as the result of my, or my guests’, acts or omissions within or around the premises of World Gym. This waiver, release and indemnification will survive the termination of my membership. I acknowledge that, at times, the facility World Gym may be unsupervised and I accept full responsibility my own actions during these times. WORLD GYM AUSTRALIA PASSPORT MEMBERSHIP (A) “Passport Membership”: A member can use participating World Gym clubs if they join up as a Passport Member depending the Passport type. When a Passport member joins their contract is with World Gym Australia. A Passport member pays a higher fee than a standard member which is a fixed rate set by World Gym Australia. A Passport member must join up at the club they most frequently use (“Home club”), and may use other participating World Gym clubs (“Away clubs”). World Gym Franchisees sell Passport memberships for World Gym Australia. (B) Transfers of Passport Memberships between clubs may automatically occur from time to time. After the initial 6 months of a Passport membership, if over a 3-month period a Passport Member’s visits are greater than 60% at an Away club and in-line with the World Gym Australia Passport Membership Policy, from that time that club will be designated as the Member’s Home club. This club will then be considered your HOME club and all other clubs AWAY clubs. Both the clubs and the Member will be notified once this change occurs. First and Last Name* ELECTRONIC 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.Signature*I hereby acknowledge that by signing: • The information provided above my health is to the best of my knowledge correct. • I will inform you immediately if there are any changes to the information provided above.