Y•Active Programme Registration Form – February 2021

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* 1. Applicants Name

Full Name

Home Address

Date of Birth - DD/MM/YYYY

Phone Number

Email address

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* 2. Gender

Female

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* 3. Ethnicity

NZ European

Maori

Pacific Island

Asian

Other

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* 4. Do you have any injuries that need to be considered?

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* 5. Have you worked out in a gym environment before?

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* 6. How fit are you?

Not Fit

Slightly Fit

Average

Higher than Average Fit

Very Fit

Not Fit

Slightly Fit

Average

Higher than Average Fit

Very Fit

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* 7. Medical

Doctor

Phone

Medical conditions/ allergies/dietary restrictions, etc.

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* 8. Emergency Contact 1

Full Name

Mobile Phone

Other Phone

Relationship to Child

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* 9. I give permission to be photographed. I understand photos and videos may be used on future YMCA South & Mid Canterbury Inc. promotional material.

Yes

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* 10. What do you want to achieve from this programme?

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* 11. How did you find out about us?

Website

Facebook

School

Word-of-mouth

Other (please specify)

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* 1. Applicants Name

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* 2. Gender

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* 3. Ethnicity

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* 4. Do you have any injuries that need to be considered?

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* 5. Have you worked out in a gym environment before?

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* 6. How fit are you?

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* 7. Medical

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* 8. Emergency Contact 1

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* 9. I give permission to be photographed. I understand photos and videos may be used on future YMCA South & Mid Canterbury Inc. promotional material.

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* 10. What do you want to achieve from this programme?

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* 11. How did you find out about us?

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* 12. By submitting this form you agree to attend every session of the Y•Active programme.