Stomp Fitness

Registration Form

Complete all fields and you are on your way to becoming a team member of the

Stomp Fitness Programme.

Your trainer will be kicking your butt into shape soon.

Name: *
Postal Address:
Email Address: *
Home Phone:
Mobile Phone:
Date of Birth:
Height:
Weight (optional)
Emergency Contact Name: *
Emergency Contact Phone: *
Previous Exercise Experience:
Why do you want to be a Stomp Fitness member?: *
Preferred Session Time/s:	Tuesday 5:30pm Thursday 5:30pm Saturday 9:00am
Do you have or have you ever suffered from:	Low/High Blood Pressure Chest Pain Respiratory Problems/Asthma Angina/Heart Attack Stroke Diabetes Kidney/Liver Disease High Cholesterol Irritable Bowel Syndrome Thyroid Issues Dizziness/Fainting Pelvic Floor/Bladder Weakness Glandular Fever Major Surgery Dislocated Joints Broken Bones Headaches Ankle/Foot Pain Shoulder Pain Wrist/Elbow Pain Back/Neck Pain Hip Pain Knee Pain Back Trauma/Injury Tingling/numb Limbs Arthritis Osteoporitis Cancer Pneumonia Low Immunity
Notes on health issues above:
Is there any other personal information regarding your health you think is necessary to disclose?
How did you hear about Stomp Fitness? *	-- Please Select One --RadioThe Body Coach | One 2 One WebsiteInternet SearchFacebookPersonal Trainer from Body Coach | One 2 OneWord of MouthGraboneOther
I acknowledge that I have read, understood & accepted the Stomp Fitness Terms & Conditions
*	YES NO
I acknowledge that my registration is not complete until I have paid my registration fee via internet banking (account details are available once you have submitted this form).
*	YES NO