3 MONTH CONTRACT FOR PENSIONERS & SCHOLARSFull Names(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title Name Surname Email Address(Required) Are you 18+ years old?(Required) Yes NoDate Of Birth(Required)Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Occupation(Required)Contact Number(Required)Address(Required) Address City Province Postal Code Doctor & Medical Aid DetailsDoctor's NameContact NumberDo you have medical aid?(Required) No YesName of medical aid and plan name(Required)Medical Aid Number(Required)QuestionnareHave you ever had one of the following: Heart Disease Asthma Gout Cardiovascular Condition High Blood Pressure Low Blood Pressure Family History of Heart Disease Dizziness Arthritis Infectious Diseases Blackouts Diabetes Fainting Epilepsy/Fits OtherComplete "Other"(Required)Do you have any problems/injuries in the following areas? Knees Lower Back Neck/Shoulders Hips/Pelvis Flexibility OtherPlease explain more(Required)Are you currently doing any regular physical activity?(Required) No YesHow many times per week?(Required)1234567Have you had surgery in the last 5 years?(Required) No YesPlease tell us more...(Required)Do you smoke?(Required) No YesHow many times per day and for how long?(Required)Are you on any medication?(Required) No YesWhat medication and when do you take it?(Required)Anything else we need to know?(Required) Nope, I'm good YesTell us more...(Required)ACKNOWLEDGEMENT RELEASE AND ASSUMPTION OF RISKWarning: This is an important document, which affects your legal rights and obligations. Please read it carefully and do not sign it unless you understand it. If you have any questions, please ask.Acknowledgment of Risks, Injury and Obligations(Required)I acknowledge that the activities I am to undertake have potential dangers and by participating in them I am exposed to certain risks. I acknowledge and understand that whilst participating in any such activities: I may be injured physically, mentally or may die; Any physical conditions I may have, of which I may or may not be aware of, which I may or may not have disclosed to the centre or its staff, may be aggravated or worsened by my participation; My personal property may be lost or damaged; Other persons participating in such activities may cause me injury or may damage my property; I may cause injury to other persons or damage their property; The conditions in which the activities are conducted may vary without warning; I may be injured or die or suffer damage to my property as a result of negligence or breach of contract of the Fitness Centre operator, or its servants or agents; and There may be no or inadequate facilities for treatment or transport of me if I am injured. I assume the risk of, and the responsibility for any injury, illness, death or property resulting from my participation in any activities.Select AllRelease and Indemnity to Fitness Centre Operator - Van Velden Biokinetics(Required)In the consideration of the acceptance of my payment (or guest status) for participating in any activity (except to the extent that the centre may be precluded by statute) I agree to release and indemnify the Fitness Centre Operator and staff as follows: I participate in the activities at my sole risk and responsibility; and I release, indemnify and hold harmless the Fitness Centre Operator, its servants and agents, from and against all and any actions or claims which may be made by me or on my behalf or by other parties for or in respect of arising out of any injury, loss, damage or death caused to me or my property whether by negligence, breach of contract or in any way whatsoever. I also agree that in the event that I am injured or my property is lost or damaged, I will bring no claim, legal or otherwise, against the Fitness Centre operator or its servants and agents, in respect of that injury, loss or damage. Before signing this document, I have read and acknowledged and know how it affects my legal rights.Select AllFull Name(Required) Name Surname ID Number(Required)Today's Date(Required)Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Signature(Required)Reset to re-sign.WHERE PARTICIPANT IS UNDER 18 YEARS OF AGE(Parent / Guardian to read and sign)Being a parent or legal guardian of the person named in this Acknowledgement and Release, I hereby acknowledge and agree:(Required)In the consideration of the acceptance of my payment (or guest status) for participating in any activity (except to the extent that the centre may be precluded by statute) I agree to release and indemnify the Fitness Centre Operator and staff as follows: I have read the whole document and understand it; I consent to the person, named in this Acknowledgement and Release, participating in the activity; and I am aware of the risks, dangers and obligations set out above in this Acknowledgement and Release. In consideration of the person named in the Acknowledgement and Release being accepted to participate in any activity, I agree to release and indemnify the Fitness Centre operator, its servants and agents, in the same manner and to the same effect and extent as if I were the person first named in this Acknowledgement and Release and the person participating in any of these activities.Select AllFull Name Of Parent/Guardian(Required) Name Surname ID Number(Required)Today's Date(Required)Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Signature Of Parent/Guardian(Required)Reset to re-sign.CommentsThis field is for validation purposes and should be left unchanged.
