ENROLLMENT FORM Enrollment FormNet Fit Program Enrollment FormMother's Name*Address*Post Code*Mobile*Email*Date MM slash DD slash YYYY Emergency Contact & Number*Child's Name*Date of Birth* MM slash DD slash YYYY Are you a member of a Netball Club?* Yes NoIf YES, which club?1. Do you or your child have, or ever had:* High Blood Pressure A heart condition or disease High Cholesterol Asthma or breathing problems Coughing during or after exercise Diabetes I or II Glaucoma Epilepsy/seizures Others2. If you ticked any of the above conditions, has a doctor treated that condition or conditions?* Yes NoIf YES, Does the treatment prevent participation in physical activity to your knowledge? Yes No3. Do you take medications or supplements for any of the above conditions?* Yes NoIf yes please write the name and dosage of medication below.4. Do you or your daughter have any joint injuries? Yes NoIf yes, please describe the injury below.5. Do you or your daughter have difficulty with: Vision Hearing Language/Speech Balance None6. In the last 12 months have you had any surgery?* Yes NoIf yes, please write below what was the surgery for:7. In the last 12 months have you or your daughter had any falls or accidents that resulted in an injury which may affect your training?* Yes NoIf Yes, please explain:8. Are you aware of any other medical reasons that may prevent you from participating in a physical activity program?* Yes NoIf Yes, please explain* The above information is, to the best of my knowledge true and correct. I will inform you of any changes in my condition. I understand that I am free to withdraw from this program at any time I desire. The information will be treated as privileged and confidential.* I understand that this fitness program may include exercises that will build my cardio-respiratory system (heart & lungs), musculoskeletal system (muscles), and decrease body fat and increase muscle mass. Exercises may include aerobic activity such as walking, running etc. Resistance training exercises using dumbbells, cables, kettle bells, bars and also flexibility exercises such as stretching to improve range of joint movement.* I understand that the use of resistance equipment can lead to musculoskeletal pain, strain and injury if properly not warmed up and if not done in gradual progression and following safety procedures.* I understand that a program of regular exercise has shown beneficial effects on decreasing the risk of heart attack, improving body composition, improved blood pressure, increased energy levels and improved psychological function.NameSignatureMax. file size: 80 MB.Date MM slash DD slash YYYY Upfront OptionAdult & Child 1 x session per week (Term 1 - 13 weeks) Quantity Price: $ 325.00 Quantity Adult & Child 2 x sessions per week Quantity Price: $ 650.00 Quantity Weekly Direct DebitAdult & Child 1 x session per week on Direct Debit per week (Term 1 - 13 weeks) Quantity Price: $ 25.00 Quantity Adult & Child 2 x sessions per week on Direct Debit per week Quantity Price: $ 50.00 Quantity Payment OptionsCredit CardAmerican ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Expiration Date Security Code Cardholder Name Δ
