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Informed Consent - Liability Waiver In consideration of being allowed to participate in the activities of the programmes of Simple Strength Leixlip which are undertaken by the selected insured Simple Strength Leixlip Instructors and to use the facilities and equipment managed/owned by Simple Strength Leixlip /or under the control of the organisers of Simple Strength Leixlip, in addition to the payment of any fee or charge, I do hereby waive release and forever discharge Simple Strength Leixlip and its organisers from any and all responsibilities or liability for injuries resulting from my participation of activities or use of the above equipment during a Simple Strength Leixlip session. I understand and am aware that strength, flexibility and aerobic exercise, including the use of equipment, in the outdoors, or assigned training areas, are potentially hazardous activities. I also understand that exercise and fitness activities involve a risk of injury and even death, and I am voluntarily participating in these activities and using equipment and facilities with the knowledge of the dangers involved. I hereby agree to expressly assume and accept all and any risks of injury or death. I am aware that I have the right to request advice from Simple Strength Leixlip instructors, in relation to the activities and exercise being undertaken with particular regard to my health and clothing. If I choose not to take advice or disregard any advice given, I do so voluntarily and accept liability for all resulting injuries and damage. I hereby declare myself to be physically sound and suffering from no condition, impairment, disease or infirmity or other illness that would prevent my participation or use of equipment or facilities except as herein stated. I acknowledge that I have either had a physical examination and have been given my doctors permission to participate, or that I have decided to participate in activity and utilisation of equipment and machinery in my activities. In addition, Simple Strength Leixlip and its organisers cannot accept responsibility for items lost during training sessions. I am aware that no discount or refund shall be given to me under any circumstances. I have read and agree to the Simple Strength Leixlip Membership Terms and Conditions. I hereby declare myself to be physically sound and healthy prior to training. I also declare that I am not taking part in any Simple Strength Leixlip class under the influence of alcohol or other inebriating substances. 




First Participant's Name
First Name*
Middle Name
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Signature*
Second Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Would you like a Free Trial Class
Thank you for your interest in our small group strength and fitness classes. We will be back in touch to confirm your free trial class time and date. Please let us know what time generally suits you best eg. Monday evenings, Saturday mornings.
Physical Activity Readiness
Do you know of any other reason you should not exercise or increase your physical activity?*
No
Yes
Do you take any medications? please list them here
Is a physician currently prescribing medications for your blood pressure or heart condition?*
No
Yes
Do you have a joint or bone problem that may be made worse by a change in your physical activity?*
No
Yes
Do you ever lose consciousness or do you lose your balance because of dizziness?*
No
Yes
When you do physical activity, do you feel pain in your chest?*
No
Yes
Do you have any condition of the heart or lungs, and should only do physical activity recommended by a physician?*
No
Yes
Do you have any medical or surgical history that you would like me to be aware of?
Do you have any mental health concern that you would like me to be aware of?
Birth History and Fertility Journey
If you have given birth in the last year, please let me know the date:
If you have ever given birth and would like me to know about any relevant details, types of birth & dates (eg. vaginal birth Jan 2017), previous birth trauma, miscarriage, termination or complications please do.
If you are going through any fertility treatment that you would like me to be aware of, please let me know here.
Pelvic Health and Gynae History
Do you experience any of the following:
Urinary or Faecal Incontinence
Pelvic Pain
Pelvic Organ Prolapse Symptoms
Heaviness, dragging or 'falling out' sensations in the pelvic floor
Have you ever been to a pelvic floor physiotherapist (a physiotherapist who helps with pelvic pain, leaking and prolapse)? Would you like to know more about pelvic floor physiotherapists in the local area?
Do you have any history of gynaecological, pelvic or abdominal surgery that you would like me to know about? Eg. Hysterectomy
Your Fitness Goals and History:
What would you like to achieve by joining Simple Strength Leixlip?
What has your experience in gyms and fitness settings been like?
Social, Cultural and Family
Is there anyting you would like me to know about your social or family background that wll impact on your experience in the gym? For example if you are a full time carer, or a parent of child with extra needs.
Is there anything you want me to be aware of in your social or cultural background?
Non-Diet Gym
Simple Strength Leixlip is a non-diet gym, which means that we don't talk about weight loss or diets in our space. Thank you for keeping this a positive space for everyone. Please type 'yes' if you understand and are happy to be a part of this community. If you would like help with body image issues, please feel free to talk to one of the coaches, who will be happy to help. *
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Middle Name
Last Name*
Relationship*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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