AQUACAMP77 Pre-Acitvity Questionnaire









Personal Information

First Name (required) Last Name (required)

Address (required)

Suburb (required) Postcode (required)

Mobile Number (required)

Home Phone Number

Your Email (required)

Date of Birth (required)

Gender (required)
 Male Female

In Case of Emergency

Emergency Contact Name (required)

Emergency Contact Number (required)

Medical Information
All medical information is kept confidential and only view by BOOTCAMP77 staff

Do any of these apply to you right now? All answers are required

Current Illness (eg: flu, fever)...  Yes No

Heart Condition (pain or tightness in chest)...  Yes No

Epilepsy, fits or blackouts...  Yes No

High Blood Pressure...  Yes No

Circulatory Problems...  Yes No

Asthma...  Yes No

Diabetes...  Yes No

Arthritis...  Yes No

Joint Damage...  Yes No

Back Problems...  Yes No

Are you pregnant?  Yes No

Have you had a baby in the past 6 weeks?  Yes No

Do you smoke?  Yes No

If you answered "Yes" to any of the above questions, please give details:

Fitness Self Assessment

How often do you exercise in a week? (required)
 None Once Twice Three Times More than 3 times

What do you rate your fitness level? (required)
 Lowest 1 2 3 4 5 6 7 8 9 10 Highest

Can you swim 20 metres? (required)
 No With the aid of a noodle/kickboard Slowly Comfortably

Do you fear any water activity (ie; face or head under water) (required)
 No Yes

Where did you hear about AQUACAMP77?: (required)

Disclosure of Medical Conditions
I represent and warrant to BOOTCAMP77 that I have disclosed details of any medical condition I have and of all recent medical treatment received by me. I have read the questions/information understand it and any questions which may have occurred to me have been answered to my satisfaction. (required)
 Agree

Indemnity and Risk Waiver
In the case of an emergency, I authorise the BOOTCAMP77 staff, where it is impractical to communicate with me, to arrange for me to receive such medical or surgical treatment as may be deemed necessary. I also undertake to pay or reimburse costs which may be incurred for medical attention, ambulance transport and drugs whilst I am in a BOOTCAMP77 program. For any child under the age of 16, Aquacamp77 takes no responsibility for in the pool and around the pool deck. (required)
 Agree

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Get in Touch With BC77

Call Us: 0404 085 361

Email Us: miriam@bootcamp77.com.au

 
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