Guest health informationPlease complete the form below before training at the club. Name * First Name Last Name Date * MM DD YYYY Phone * (###) ### #### Email * Have you ever experienced chest pain brought on by physical activity? * Yes No Do you lose consciousness or fall due to dizziness? * Yes No Do you have any joint or bone problems? * Yes No Have you taken medication for blood pressure / heart problems? * Yes No Are you diabetic? * Yes No Do you suffer from asthma? * Yes No Do you have high or low blood pressure? * Yes No Do you have a family history of heart problems / disease? * Yes No Are you aware of any reason from a doctor or your own experience why you should not exercise without medical supervision? * Yes No Are there any health related issues that you have not told us about? * Yes No If you have answered yes to any of the above questions, please add further details: How did you find out about us? * Next of Kin * First Name Last Name Phone number for next of kin * (###) ### #### I undersigned having completed the above questionnaire and I am aware that exercise and physical activity including the use of the track is potentially hazardous. I understand that participating in physical activity may result in injury and possibly even death and that I choose voluntarily to take part in these activities. I will assume responsibility for any minors (under 18’s) who are accompanying me whilst visiting “East Cheshire Harriers and Tameside AC’. * Todays date * MM DD YYYY Thank you for completing the form, you can now train at the club!
