Step 1 of 4:

Kappatalize Fitness Pre Activity Questionnaire

Full Name*
Preferred Location

Step 1 of 4: General details (cont.)

Date of Birth*
Emergency contact name*
Emergency Contact Relationship & Mobile *
How did you hear about us? *

Step 2 of 4: Pre-Activity Questionnaire

Health Questionnaire
1. Have you sought advice from your medical practitioner with regards to undertaking a fitness program?*
2. Are you currently undertaking a fitness program or exercising? Please list details. *
3. Do you have any current or previous injuries? *
If yes, please list date of injury(s), type of injury, treatment including practitioner type.
4. Do you have any chronic illness or see a doctor regular for a particular illness (E.g.: diabetes, asthma, epilepsy, athritis etc)*
If yes, please list
5. Do you take any prescribed or over the counter medication. Please list if yes, or enter "No" if no.*

Pre-Questionnaire (Cont.)

General Health Questions
1. Do you have ongoing back, pelvis, groin or abdominal pain? *
2. Do you feel pain in any other joints in your body? *
3. Do you suffer from pins and needles on a recurring basis?*
4. Do you experience difficulty breathing or feel short of breath when exercising or in general?*
5. Do you experience episodes of dizziness? *
6. Have you ever had abnormal heart rate, palpitations or irregular heart beats? *
7. Do you have high blood pressure or high cholesterol? *
8. Do you have any diagnosed muscle, bone or joint problems that could be made worse by exercise or physical activity? *
9. Do you have any other medical condition(s) that may make it dangerous for you to participate in exercise or physical activity? *
If you answered yes to any of the above, please provide further details.


Please confirm your understanding by ticking each box.
“Training and fitness activities and programs” includes but is not limited to personal training, fitness classes, team or individual competitions, fitness assessments, use of equipment and facilities, powerlifting, lifting, strength, conditioning, metabolic training, plyometrics, interval training, bodyweight conditioning, stretching, outdoor running on trails, sidewalks or paths, sports and programs, clinics, seminars, and services provided to the client by Kappatalize Fitness.
I wish to participate in the activities and programs of P & C Solutions Pty Ltd trading as Kappatalize Fitness (ABN 90165227636)*
I understand that a) Portions of the exercise and training program occur outdoors and/or indoors b) Exercise carries some risk including, without limitation risk to theo the musculoskeletal system and to the cardio respiratory system*

To release Kappatalize, its employees and representatives from any and/or all responsibilities and /or liability from injuries or damages, however caused, resulting from or ancillary to my participation in any activities and my use of the equipment, including but not limited to, by slip/fall, negligence of an instructor or other person, defective or improper use of equipment, over-exertion or unknown health problems.*
To waive any and all claims that I have or may have in the future against Kappatalize and their owners, volunteers, directors, officers, employees, trainers, instructors, agents, officials, independent contractors, servants, representatives, successors and assigns (all of whom are hereinafter referred to as the “RELEASEES”) and TO RELEASE THE RELEASEES from any and all liability for any loss, damage, expense or injury including death that I may suffer or that my next of kin may suffer as a result of my participation in climbing and transportation activity DUE TO ANY CAUSE WHATSOEVER, INCLUDING NEGLIGENCE, BREACH OF CONTRACT, OR BREACH OF ANY STATUTORY OR OTHER DUTY OF CARE, ON THE PART OF THE RELEASEES, AND INCLUDING THE FAILURE ON THE PART OF THE RELEASEES TO SAFEGUARD OR PROTECT ME FROM THE RISKS, DANGERS AND HAZARDS OF KAPPATALIZE training and fitness activities and programs;*
TO HOLD HARMLESS AND INDEMNIFY THE RELEASEES from any and all liability for any property damage or personal injury to any third party resulting from my participation in Kappatalize training and fitness activities and programs;*
TO HOLD HARMLESS AND INDEMNIFY THE RELEASEES from any and all liability for any costs they may incur for medical costs, emergency transportation, and litigation resulting from my participation in Kappatalize training and fitness activities and programs;*
That this Agreement shall be effective and binding upon my heirs, next of kin, executors, administrators, assigns and representatives, in the event of my death or incapacitation*
This Agreement and any rights, duties and obligations as between the parties to this Agreement shall be governed by and interpreted solely in accordance with the laws of NSW Australia and no other jurisdiction.*
I understand and am aware that strength, flexibility and aerobic exercise, including that use of equipment is a potentially hazardous activity. I also understand that fitness activities involve a risk of injury, including but not limited to heart attack, muscle strain, pulls or tears, broken bones, shin splints, heart prostration, knee/shoulder/arm/back/foot/leg injuries, and/or death.*
I understand that I am voluntarily participating in these activities and using equipment with knowledge of the dangers involved. I agree to expressly assume and accept any and all risk or injury or death. I further declare myself to be physically sound and suffering from no condition, impairment, disease, or other illness that would prevent my participation in exercise programs or use of equipment.*
I acknowledge that I have been informed of the need for a physician’s approval for my participation in and exercise of fitness activity or in the use of exercise equipment. I also acknowledge that it has been recommended that I have a yearly or more frequent examination and consultation with my physician as to physical activity, exercise and use of exercise and training equipment, so that I might have his/her recommendations concerning these fitness activities and equipment use.*
I acknowledge that I have either had a physical examination and been given my physician’s permission to participate, or that I have decided to participate in the activity and use of the equipment without the approval of my physician and assume all responsibility for my participation in activities, and utilisation of equipment in my activities. In entering into this Agreement I am not relying on any oral or written representations or statements made by Kappatalize with respect my safety .*
Finally, I acknowledge and agree that no warranties or representatives have been made to me by any representative of Kappatalize in respect of the safety of Kappatalize training and fitness activities and programs other than what is set forth in this Agreement nor in respect of the results I will or may achieve from any program conducted by Kappatalize. I understand that results are individual and may vary.*

Release of Photography and Video

I hereby authorise Kappatalize Fitness to publish photographs and videos taken of me for use in Kappatalize's print, online and video-based marketing materials and social media, as well as other publications. I hereby release and hold harmless Kappatalize Fitness from any reasonable expectation of privacy or confidentiality associated with the images and videos specified above. I further acknowledge that my participation is voluntary and that I will not receive financial compensation of any type associated with the taking or publication of these photographs or participation in company marketing materials or other Company publications. I acknowledge and agree that publication of said photos confers no rights of ownership or royalties whatsoever. I hereby release Kappatalize Fitness, its’ contractors, its’ employees, and any third parties involved in the creation or publication of marketing materials, from liability for any claims by me or any third party in connection with my participation.*

Agreement to Terms and Conditions

By submitting this form, I agree to the terms and conditions listed by Kappatalize Fitness - see FAQ and Terms and Conditions sections for details*
Signed Date*

After hitting "Next", you will be directed to the $2 trial or package payment processing.

Emergency Contact Phone(1)*