PT - Whanake House - The Y Southland

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Client Details

Name(Required)

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone number (if applicable)

Date of birth

Gender

Diagnosis

Whanau Support

Name

First Last

Phone number

Email(Required)

Enter Email Confirm Email

Client goals

What are your objectives? (Weight loss, toning, strength, power, muscular endurance, cardio fitness, flexibility, core stability, balance etc)

Why do you want to achieve these goals? (Ie. general health, injury prevention, rehab, sport specific training, aesthetic reasons etc)

Health information

Do you have any current or history of bone, muscle, or joint injuries or conditions (arthritis, strains, or sprains)?

Upper back

Lower back

Neck

Shoulders

Hips

Knees

Ankles

Elbows

Wrists

Do you have any of the following medication conditions?

Heart problems

Diabetes Type 1

Diabetes Type 2

Asthma

Seizures

Neurological problems

Dizziness

High blood pressure

Hernia

Surgery in the past 12 months

Is there anything else we should know in relation to your health, so we can best support your health and fitness goals?

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Important information(Required)

I have read and understood the important information

Our desire is to help you reach your health related and/or training goals as fast as and effectively as possible. While on this journey we would like to provide you with information that will enable you to continue the health and wellbeing benefits achieved in our training so that you will attain a life of longevity and health.

Important guidelines

• Eat something substantial 1.5 hours prior to training
• Drink two glasses of water 30 minutes before training
• Bring all medications you may need for training, such as an inhaler, insulin, adrenaline etc
• Bring a towel and water bottle with appropriate clothing

If you are feeling under the weather, had a tough day or just a bit down and not at your peak performance please be honest with us so we can tailor your session to suit.

Cancellation
If we cannot provide you with 24 hours’ notice for the cancellation of a session, we will provide you with a complementary session. Similarly, if you cannot provide us with 24 hours’ notice of a session and we cannot rebook that session within a seven-day period the payment for that session will be forfeited.

Limitation of liability
YMCA Southland shall not be liable for any injury, loss or damage of the client other than where such loss or damage is due to the negligence of the Y Southland. However, the Y Southland’s liability shall not extend to indirect, consequential, special, or economic loss.

Photo/Video Release and Consent

I consent to my photos/videos being used for marketing and reporting purposes.

The client consents to photos or videos of the activity being used for reporting to funders and/or publicity material used by the Y Southland.

Collection of information(Required)

I have read and understood the reasons for the collection of my personal information and understand it complies with the Privacy Act 2020.

The client acknowledges that personal information collected or held by the Y Southland (whether obtained in this form or otherwise obtained) is designed to support the services delivered to the client.
Information gathered will be collected and stored in line with the Privacy Act 2020, and is available for the client to have access to. The client may request correction of any personal information held by the Y Southland concerning the client.