Title MrMrsMsMasterMissOther (please state)
Date of Birth
Home Telephone No.
Mobile Telephone No.
Emergency Contact Name
Emergency Contact Telephone No.
Have you ever used a gym or fitness equipment before? YesNo
Do you suffer from or experience any complications as a result of having had any of the following? YesNo
Heart Disorder/Disease YesNo
Circulatory, Blood Pressure Problems YesNo
Neurological Problems/Stroke YesNo
Lung/Respiratory Disease YesNo
High Cholesterol YesNo
Skeletal, Back, Neck, Joint, Muscle Problems YesNo
Stress, Depression, Anxiety, YesNo
Have you had any surgery, illness or accident that may affect your ability to exercise or use any piece of fitness equipment? YesNo
If you have answered yes to any of the questions above, please provide further details below:
If you consider yourself to have a form of disability, please provide further details below:
Stonyhurst College only collects data for the purpose indicated on this form and will not distribute or share this information with any third party.
Physical exercise can be strenuous and as a member of the Stonyhurst Sports Centre, you can be subject to risk of serious injury. The Stonyhurst Sports Centre urges you to obtain a physical examination from a doctor before using any exercise equipment of participating in any exercise activity.
Members (each client, guest, and all participating family members) agree that if they engage in any physical exercise or activity, or use any gym amenity on the premises or off premises, including any sponsored gym event, you do so entirely at your own risk. You as the member agree that you are voluntarily participating in these activities and use of these facilities and premises and assume all risks of injury, illness, or death. We are also not responsible for any loss of your personal property.
This waiver and release of liability includes, without limitation, all injuries which may occur as a result of:
1) Your use of all amenities and equipment in the facility and your participation in any activity, class, program, personal training or instruction
2) The sudden and unforeseen malfunctioning of any equipment
3) Our instruction, training, supervision, or dietary recommendations
4) Your slipping and/or falling while in the building, or on the premises
5) Contact with other participants
6) The effects of the weather, including high heat and/or humidity; and all other such risks being known and appreciated by me
By signing this waiver, you expressly acknowledge:
If any portion of this release from liability shall be deemed by a court of competent jurisdiction to be invalid, then the remainder of this release from liability shall remain in full force and effect, and the offending provision of provisions severed her from.
By signing this release, I acknowledge that I understand its content and that this release cannot be modified orally.
I agree to the above