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Medical Conditions Please tick if ANY Medical Conditions Please tick if ANY Anyone in your family under 60 suffered heart disease, stroke, raised cholesterol or sudden death? Have you been hospitalised recently? Do you have any infections or infectious diseases? Diabetes Rheumatic fever Any heart condition Raised cholesterol triglycerides Heart murmur Are you on any prescribed medications? Have you given birth in the last six weeks? Gout Hernia Stomach or duodenal ulcer Blood pressure greater than 140 over 90 Epilepsy Are you pregnant? Stroke Glandular fever Liver or kidney condition Palpitations pains in the chest Dizziness or fainting

Medical Conditions (Please tick if you ticked ANY of the above) Medical Conditions (Please tick if you ticked ANY of the above) ALREADY CLEARED THE ABOVE CONDITION(S) WITH YOUR DOCTOR

Do you have any of the following? Do you have any of the following? Arthritis Cramps Muscular pains Wrist Injury/Pain Neck Injury/Pain Back Injury/Pain Shoulder Injury/Pain Leg Injury/Pain Do you smoke?

Are you dieting/fasting - If so please give details

Exercise intensity in last 3 months Exercise intensity in last 3 monthsLightModerateVigorous

Do we need to consider any other conditions that you may have for exercise modification? If so, what are they?

WARNING: I acknowledge and agree that: physical activity/exercise may cause serious injury or death – caused by me, other people around me, my personal trainer, or improper use or failure of equipment; these activities/exercises may involve weightlifting, strenuous exercises or movements, and other high exertion activities, and that I am not obliged to do any of these things, and I can stop at any time or ask for assistance; and it is completely my own choice to undertake and participate in this activity/exercise, and it is at my own risk. WARNING: I acknowledge and agree that: physical activity/exercise may cause serious injury or death – caused by me, other people around me, my personal trainer, or improper use or failure of equipment; these activities/exercises may involve weightlifting, strenuous exercises or movements, and other high exertion activities, and that I am not obliged to do any of these things, and I can stop at any time or ask for assistance; and it is completely my own choice to undertake and participate in this activity/exercise, and it is at my own risk. I AGREE to the ABOVE TERMS & CONDITIONS I declare that the information provided by me on the above form is true and correct to the best of my knowledge

DISCLAIMER: In consideration of the above, I release Street Workout St Kilda – ABN 65 714 394 898 (including its directors, owners, agents, employees, trainers, workers and volunteers) from any and all liability, claims, demands, actions or rights of action, which are related to, arise out of, or are in any way connected with my participation in this activity/exercise, including those allegedly attributed to the negligent acts or omissions of any or all of the above mentioned parties. I acknowledge that I have answered the questions in this form truthfully and correctly. I acknowledge that where I have indicated YES to a question I have checked with my doctor to ensure it is safe for me to undergo a fitness assessment and/or begin my exercise program with Street Workout St Kilda. By signing this document I acknowledge that I understand that these terms affect my legal rights. DISCLAIMER: In consideration of the above, I release Street Workout St Kilda – ABN 65 714 394 898 (including its directors, owners, agents, employees, trainers, workers and volunteers) from any and all liability, claims, demands, actions or rights of action, which are related to, arise out of, or are in any way connected with my participation in this activity/exercise, including those allegedly attributed to the negligent acts or omissions of any or all of the above mentioned parties. I acknowledge that I have answered the questions in this form truthfully and correctly. I acknowledge that where I have indicated YES to a question I have checked with my doctor to ensure it is safe for me to undergo a fitness assessment and/or begin my exercise program with Street Workout St Kilda. By signing this document I acknowledge that I understand that these terms affect my legal rights. I AGREE to the ABOVE TERMS & CONDITIONS I declare that the information provided by me on the above form is true and correct to the best of my knowledge

I AGREE that in SOME Instances DURING SESSIONS, Material May be Obtained for the Purpose of Marketing I AGREE that in SOME Instances DURING SESSIONS, Material May be Obtained for the Purpose of Marketing I AGREE