QMU SPORTS – Teen Gym
Membership Form
Member
Guest
Paid Joining Fee
Staff
Membership Card Number
To be completed by a parent or guardian.
Personal Details of Member:
Name: ______________________________
Address:_______________________________________________________________________
Post Code: _______________________________
Tel.No.__________________________________Email:________________________________
D.O.B:___________________________________
Par Q
Yes
No
Do you feel pain in your chest when you do physical activity? Or do you suffer from a heart condition?
Are you Diabetic?
Are you pregnant or have you been pregnant in the last 6 months?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Are you currently taking any medication?
Do you know of any other reason why you should not do physical activity?
Do you suffer from any bone or joint problems?
Do you have any allergies?
If you answered yes to any of the above please give details:
If your child’s health changes and the answer to any of the above become Yes please inform the sports staff
immediately and consult a doctor before continuing to exercise
Parent/Guardian details:
Declaration:
Name: _________________________________________
Tel.Number: ____________________________________
I give my permission for my son/daughter to take part in the Teen Gym programme at QMU Sports. I have
read, understood and completed this questionnaire on behalf of my son/daughter and all information is
accurate and a true reflection of their health at this time. I give my permission for my son/daughter to have
their photograph taken for membership purposes.
Please note that QMU does not accept responsibility for personal injury caused from using the facilities or
equipment
Parents Sign: ________________________________________________ Date: _________________________
Members Sign:_____________________________________________________