Junior Athletics new sign up Jr Athletic Program Attendee Name*Date of Birth* DD slash MM slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email* Phone Number*Emergency Contact Name*Emergency Contact Number*How did you hear about us?Please SelectExisting ClientCaribeae Swimming ClubDoctor ReferralFacebook PromotionGoogle SearchHamish Ashton – PhysiotherapistI am a current clientMiche Hansen – PhysiotherapistReferral from Friends or FamilySchool ReferralVector Health WebsiteOtherAgreement I hereby agree to assume all risks and responsibilities surrounding my (or my child’s) participation in the program under the instruction of Vector Health coaches. I understand that similar to all sporting activities, there is a risk of damage to personal property, injury or death which may result from causes beyond the control of, and without fault or negligence of Vector Health, its officers, agents, or employees, during the period of my (or my child’s) participation. I understand completely the above agreement and agree to be bound thereby. By registering on our site you agree that we may send you email related to our facilities and programs. We will not provide your details to any other company.Agree* I agree to the terms and conditions outlined above Photography* I, the undersigned, hereby authorize Vector Health to photograph me, take motion pictures of me, take video footage of me, and/or make electronic sound recordings of me (herein referred to as photographic or electronic reproductions). Photographic Usage* I authorize the use of any such photographic or electronic reproductions of me for any purpose, including, but not limited to educational and other public media as may be deemed appropriate by Vector Health (I understand that I may be identifiable from such photographic or electronic reproduction) Is the person being enrolled under the age of 18?*Please SelectYesNoParental Consent* This applies if you are enrolling a child under the age of 18 years in your care. I certify that I am the parent or guardian of the individual above who is a minor under the age of eighteen years. I hereby agree to assume legal responsibility for his/her authorizations referred to in this General Media Release. SignatureAPSS Screening Tool COMPULSORY Adult Pre-Exercise Screening Tool – STAGE 1 only. This questionnaire determines a level of health risk. It is very important that you are upfront and honest with your answers. Answering NO to any of these questions does not mean you cannot do exercise, however it does mean that you present with a risk factor for injury or illness during or post physical activity or exercise.Who is your normal General Practitioner?*What medical Clinic is your General Practitioner from?*Has your doctor ever told you that you have a heart condition or have ever suffered a stroke?* Yes No Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?* Yes No Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?* Yes No Have you had an asthma attack requiring immediate medical attention at any time over the past 12 months?* Yes No If you have diabetes (Type I or type II) have you had trouble controlling your blood glucose in the last 3 months?* Yes No Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?* Yes No Do you have any other medical conditions that may make it dangerous for you to participate in physical activity/exercise?* Yes No Chosen days of the week for a 10 week term* Tuesday 6am -Advanced Class Thursday 6am- Advanced Class Tuesday and Thursday 6am – Advanced Class Total $ 0.00 NameThis field is for validation purposes and should be left unchanged.
