Full Name *

Date of Birth *

Email Address *

Phone Number *

Emergency Contact Name *

Emergency Contact Phone Number *

Do you have a bone or joint problem which could be made worse by exercise? *
—Please choose an option—YesNo

Have ever been diagnosed with any of the following: *
Heart diseaseHigh blood pressureAny other cardiovascular problemsDiabetesAsthmaEpilepsyNone of the above

Do you experience light-headedness or dizziness during physical exertion? *
—Please choose an option—YesNo

Have you ever suffered from any of the following: *
Accountable chest painUnaccountable chest painNone of the above

Are you or have you been pregnant in the last 3 months? *
—Please choose an option—YesNo

I hereby state that I have read, understood and answered honestly the questions above *
—Please choose an option—Yes

I understand that it is my responsibility to inform Lesley Mitchell Fitness if there any changes to my medical condition *
—Please choose an option—Yes

I have read and understood the disclaimer on the Lesley Mitchell Fitness Live website page *
—Please choose an option—Yes

Type of Class *
OnlineFace-to-Face

Any other comments?

Please Note: The information you provide on this Consent Form will only be used by Lesley Mitchell Fitness and will not be shared with any other third-parties.