Child Registration - Gym Services

Kids World - World Gym Burpengary

Confidential and Subject to Approval by Supervisor All sections must be completed before a child can be enrolled. Please notify us promptly of any changes. CHILDRENS DETAILS:

I'm registering my child for:

How Many Children would you like to enroll?*

Child Name*

Birthday*

Gender*

Male
Female

Child Name*

Birthday*

Gender*

Male
Female

Child Name*

Birthday*

Gender*

Male
Female

Child Name*

Birthday*

Gender*

Male
Female

Child Name*

Birthday*

Gender*

Male
Female

Child Name*

Birthday*

Gender*

Male
Female

PARENT/GUARDIAN 1- First and Last Name*

Address

Street Address

Gender*

Male
Female

Mobile Number:*

Work Phone Number:

Home Phone Number:

PARENT/GUARDIAN 2

Gender

Male
Female

Mobile Number:

Work Phone Number:

Home Phone Number:

EXTRA EMERGANCY CONTACTs (Name of 2 people who may be contacted any time if parent/guardians unavailable, optional)

Full Name

Phone

Full Name

Phone

AUTHORISATION TO COLLECT YOUR CHILD/REN We require you to provide the names of the persons authorised to collect your children from the Centre. Please note that we will not allow any person to collect your children other than those listed below. Any change will only be accepted by written authority by the parent signing below. Please include parent’s names on the list.

Full Name

Relation to Child

Full Name

Relation to Child

Full Name

Relation to Child

Family Doctor (optional)

Name:

Address

Street Address

Contact Phone Number

Medicare Number

Are there any medical or physical conditions from which your children suffers that need to be brought to the attention of the Supervisor? Does your child have a disability? Do we need to pay attention to any particular need or behaviour? Please give details:

Details:

We regret that we are unable to care for sick children or children with contagious illnesses.

Have any of your children not completed toilet training?*

No
Yes

Please specify which children and what stage?*

CONDITIONS By enrolling my children I agree to the following conditions: 1. Children are only accepted into the crèche from 6 weeks of age. 2. I am willing for my child/ren to participate in all activities offered in the crèche. I agree it is my responsibility to familiarise myself with the program and to advise the Centre in writing if I do not wish my child/ren to participate in a particular activity. 3. In the event of accident or illness suffered by my child/ren, the organisers of the Centre Crèche are authorised to obtain, on my behalf, such medical assistance as my child/ren may require and I agree to reimburse the organisers for any expense incurred. 4. Although every care will be taken, Centre Staff are free from all responsibility for accidents or loss of property in connection with any child’s participation. 5. The Centre reserves the right to exclude children from the Crèche for misbehaviour that is deemed inappropriate. NOTE: in the event of suspension or expulsion from the Crèche, it is the parents’ responsibility to have the child collected immediately. No monies will be refunded for that session. 6. The Centre reserves the right to refuse any child or person entry to the Crèche. 7. COVID-19 I understand that my child/ren maybe part of a random temperature checked on entry and understand that if they exceed the 38 degrees, they will not be able to enter. You child will have two readings.

Consent*

DECLARATION

I declare that the information above is complete and accurate, and I have read, understood and agree to the conditions outlined above.

I understand and agree that all times my child/ren shall be at my own risk and I will not hold the Company, the centre or its staff liable for any personal injury which may result to my child or loss of property except for any liability by the Company if it fails to render its services with due care and skill or supplies any material in connection with those services which is not reasonably fit for the purpose for which they are supplied.

Behavioral Expectations:

I agree to the privacy policy.

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.

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 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:

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

Yes
No

Please provide details:

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

Yes
No

Please provide details:

Other?

Yes
No

Please provide details:

BONE/MUSCLE SYSTEM

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

Yes
No

Please provide details:

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 aponia

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 administrator for diabetes
Have a chronic disability or chronic illness
Allergic to food, medication, pollens or any other allergens or specific environments?
Follow a special diet
Been diagnosed with a nutritional deficiency

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.

Electronic Signature for Parent/Guardian*

I understand by typing in my name and pressing submit, that the information is true and correct.

Signature

World Gym Burpengary | 159-161 Station Road, Burpengary Q 4505 | P 3053 3170 | E: reception@worldgymburpengary.com.au