Name *
Name
Address *
Address
Phone *
Phone
Date of Birth *
Date of Birth
Please list any injuries, chronic illnesses (diabetes, COPD, asthma, etc), chronic aches and pains, previous surgeries, or any other physical condition or ailment that may manifest itself during training or affect your training? Please describe ALL relevant conditions in full detail
Are you currently taking any medications? If so, please list each one and your current corresponding dosages:
Current Fitness Level *
What is your main goal or reason for joining MBGVI?
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem (i.e. back, knee or hip) that could be made worse by a change in your physical activity?
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?
Please provide your electronic signature (full name).

If you answered yes to any of the previous questions please read Disclaimer.

MONKEY BAR GYM VANCOUVER ISLAND | TERMS OF SERVICE

Please check the Monkey Bar Gym Vancouver Island information you've entered above (feel free to change anything you like), and review the Terms of Service below.

ACKNOWLEDGEMENTS AND WAIVER & RELEASE OF LIABILITY

Kathleen Neilson and Simon Young d/b/a Monkey Bar Gym Vancouver Island ("MBGVI")

By signing your electronic signature and clicking on 'submit form' below you are agreeing to the Terms of Service above and the Privacy Policy