3-1-5 Declaration of Medical Needs for Group Exercise

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* 1. What is your Full Name?

First Name

Surname

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* 2. Please enter the best telephone number should we need to contact you:

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* 3. Please enter your date of birth:

.

Date

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* 4. Do you access Group Exercise Classes for support with a diagnosed condition? If yes, please state what it is: *

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* 5. Have you discussed and/or sought verbal permission from your GP/ Specialist or mental health professional? If yes please state who? Include name and address of practitioner*

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* 6. If not, please state your reasons for seeking support through 3-1-5 Group Exercise Classes? *

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* 7. I confirm my above answers are honest and true to the best of my knowledge, and I am responsible for advising 3-1-5 if any of the above circumstances change.

Agree