PERSONAL DETAILS

MR/MRS/MISS: ……….… FIRST NAME: ………………………

SURNAME: ……………….…. MALE/FEMALE: ……….. DOB: ……………
ADDRESS: ………………………………………………………………….…………
PHONE: HOME: ……………. WORK: …………………………….
MOBILE: ……………………..
OCCUPATION: ……………………………………………………………….……...
EMAIL ADDRESS: …………………………………………………………………..
EMERGENCY CONTACT: NAME: ……………………………………………….
RELATIONSHIP TO YOU: …………………
PHONE: HOME: ……………………. MOBILE: …………………………..
HOW DID YOU HEAR ABOUT ME? ………………………………………………

MEDICAL SCREENING QUESTIONAIRE

DO YOU HAVE, OR HAVE YOU HAD ANY OF THE FOLLOWING:
1. Heart disease or any other Cardio Vascular condition? Y/N
2. High/Low Blood Pressure? Y/N
3. Any family history of Coronary Heart Disease? Y/N
4. Any family history of any other illness or disease? Y/N
If so, what?
………………………………………………………………………………………………….

………………………………………………………………………………………………………………………
…
5. A major illness, injury, or surgery? Y/N
If so, what are they?
………………………………………………………………………………….
………………………………………………………………………………………………………………………..……………………………………………………………………………………………………………………………
.
6. Diabetes? Y/N
7. Epilepsy? Y/N
8. Do you smoke tobacco? Y/N
9. Arthritis or other joint/muscular pain? Y/N
10. Asthma or difficulty breathing? Y/N
11. Dizziness, blackouts or fainting spells? Y/N
12. Are there any reasons why you should not do physical activity?
Y/N
If so, what reasons?
…………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
…

CONSENT FORM
In consideration of gaining access to participate in activities associated with Jenny
Boggis High Performance Surf Coaching and Personal Fitness Training, I do hereby
waive, release and forever discharge Jenny Boggis High Performance Surf Coaching
and Personal Fitness Training from any and all responsibilities or liability for
injuries or damages resulting from my participation in said program………… (Please
initial).

I understand the policies and procedures set forth by Jenny Boggis High
Performance Surf Coaching and Personal Fitness Training and I have had the
opportunity to discuss my specific needs in relation to participatory activity; and, as
a result, I do voluntarily request the right to participate in this exercise
program………… (Please initial).

Also in consideration of the above factors, I acknowledge the existence of risks in

connection with these activities, assume such risks, and agree to accept the
responsibilities for any injuries sustained by my participation in the course via the
use of facilities and/or its equipment…………(Please initial).

Having read the preceding, I acknowledge full understanding of those risks set forth
herein and knowingly agree to accept full responsibility for my own exposures to
such risks and to waive full responsibility and liability on behalf of Jenny Boggis
High Performance Surf Coaching and Personal Fitness Training …………(Please
initial).

Participants
Name…………………………………………………………………………………………………….
Participants
Signature……………………………………………………………………………………………..
Date……………………………………………………..

Parents/Guardian’s Signature (if

applicable)………………………………………………………
Date……………………………………………………..

PERMISSION TO DINE OUT

I give permission for.............................................(name) to dine out unattended
whilst staying under Jenny Boggis Goslings supervision.

Participants
Name…………………………………………………………………………………………………….
Participants
Signature……………………………………………………………………………………………..
Date……………………………………………………..

Parents/Guardian’s Signature (if

applicable)………………………………………………………
Date……………………………………………………..

DIETARY REQUIREMENTS
Does the client have any food allergies? If so, what are they?
.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Does the client have and food dislikes? If so, what are they?
.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Does the client have any special dietary requirements? If so, what are they?
.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Participants
Name…………………………………………………………………………………………………….
Participants
Signature……………………………………………………………………………………………..
Date……………………………………………………..

Parents/Guardian’s Signature (if

applicable)………………………………………………………
Date……………………………………………………..

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