FREE TRIAL SIGN UP FORM Step 1 of 5 - Personal Details 20% Select Location*CBD – Flagstaff GardensCarlton – Princes ParkDocklands – Docklands ParkMoonee Ponds – Queens ParkNorthcote – All Nations ParkNorth Fitzroy – Edinburgh GardensCarlton Sessions*Select Session6– 7am Tuesday morning6 – 7am Thursday morning (Boxing)CBD Sessions*Select Session6 – 7pm Monday evening6 – 7pm Wednesday evening (Boxing)7 – 8am Tuesday morning7 – 8am Thursday morning (Boxing)Docklands Sessions*Select Session12 – 1pm Monday evening12 – 1pm Wednesday evening (Boxing)Moonee Ponds Sessions*Select Session6– 7am Monday morning6 – 7am Wednesday morning (Boxing)6 – 7am Friday morning6 – 7pm Monday evening6 – 7pm Wednesday evening (Boxing)7 – 8am Saturday morning8 – 9am Saturday morning9.30 – 10.30am Monday Mums n Bubs9.30am – 10.30am Wednesday Mums n Bubs9.30am – 10.30am Friday Mums n Bubs8.30am – 9.30am Monday Mums n Bubs8.30am – 9.30am Wednesday Mums n Bubs8.30am – 9.30am Friday Mums n BubsNorthcote Sessions*Select Session6 – 7am Monday morning6 – 7am Wednesday morning (boxing)6 – 7am Friday morningNorth Fitzroy Sessions*Select Session6 – 7am Monday morning6 – 7am Wednesday morning (boxing)6 – 7am Friday morning7 – 8am Monday morning7 – 8am Wednesday morning (boxing)7 – 8am Friday morning6.30pm – 7.30pm Tuesday evening6.30pm – 7.30pm Thursday evening (Boxing)8.30am– 9.30am Saturday morningTrial Date* Name* First Last Email* Address City State / Province / Region ZIP / Postal Code Phone*D.O.B Next of Kin: NameNext of Kin: Phone Please select the areas that interest you Personal Training Bootcamp Corporate Mums & Bubs Other Have you used a fitness trainer?YesNoIf yes, why did you stop?Have you recently been a member of a gym?YesNoIf yes, why did you stop?Have you tried group fitness training?YesNoIf yes, why did you stop?Fitness Goals General wellbeing Increase cardiovascular fitness Injury prevention/rehabilitation Raise energy levels Reduce body fat/weight Reduce stress levels Socialising Sporting event/race Tone up 12 Months goal Exercise HabitsHow much physical exercise do you perform per week Jogging/running Swimming Cycling Resistance Training (weights) Aerobics Walking Team sports Solo sports (eg. golf) Stretching/yoga/Pilates Other hrs per week in total(in hours, eg 4hrs)If you exercise on a weekly basis, how often per week?1 day1 - 22 - 33 - 4DailyHealth HistoryHave you experienced or suffered from: Anxiety/depression/stress Asthma Bronchitis Cancer Cardio vascular disease eg heart disease Diabetes type I or II Epilepsy Had a immediate family member had heart disease, strike, or high cholesterol under 65 years old? Hernia High Cholesterol Migraine/Headache Osteoporosis/Osteo Arthritis Pain/tightness in chest Pregnant or given birth in the last 8 weeks Stomach or intestinal problems Are there any other medical conditions that may effect performing exercise? If yes, please provide detailsDo you take medication for the following? Anxiety/depression/stress Asthma Back/neck pain Cancer Diabetes Type I Heart Disease High Blood pressure Joint Inflammation Migraine/Headache Other acute pain OtherMedications Injury check list Back Problems Broken Bones/joint pain/inflammation Knees and ankle problems Ligament Strains/tears Muscular Strains/tears Neck Problems Shoulder, elbow, wrist problems Other Add detailsAre you currently receiving treatmentYesNoOld/New injury? Old injury New injury If yes, what treatment?Have you had a surgical procedure in the past 12 months?YesNoIf yes, please provide detailsAny other relevant condition that hasn’t been mentioned? Quick QuestionnaireHow did you find out about Fitstyler? Web-Google Social Media (Facebook, Twitter, etc) Friends or family Park Signage Promotional Flyer Referral-Doctor, Physiotherapist etc Advertisement Saw training in park Web-Directory Other Name of referral*I am happy to subscribe to the monthly newsletter YES All the information provided is true and correct* YES Disclaimer. Please note the questions do not form part of any dietary or exercise program. If you have any concerns about any areas highlighted above, please seek the assistance of a Medical Practitioner.Terms and Conditions* I have read and agree to the Terms and Conditions If under 18 years old: Yes Guardian Name This iframe contains the logic required to handle Ajax powered Gravity Forms.