Fitness Centre
Guest Membership
Title (Please circle): Mr
Mrs Miss Ms Other
Forename:
Surname:
Ex-Student:
Subject Studied:
Staff Family:
Staff Name:
Graduation Year:
Family Connection:
Date of Birth:
Emergency contact Name:
Tel. No:
Address:
Relationship:
Correspondence Address:
Postcode:
Mobile Phone Number:
Home Phone Number:
e-mail Address:
Membership Type:
Expiry Date:
Payment Method:
Cost:
By signing this membership form you are agreeing to abide by the rules, regulations and etiquette of the Fitness
Centre as detailed on your members welcome letter. Your entitlement to use of Fitness Centre facilities and services
will end on the membership expiry date stated above.
All parts of the information on this form may be stored in manual and/or computer files and used for the purposes of
Sport and Recreation administration. Such use will be subject to the Data Protection Act 1998.
Signature:
Date:
Membership Number:
Induction Date:
Payment Received:
Reciept Issued:
Card issue Date:
Card Received (Member Signature):
On signing for your card you are accepting personal responsibility for the card.
Membership card must be produced on each visit to the fitness centre.
A £10 charge will be levied to replace lost membership cards.
NOTES
Health Screen
Forename:_________________________ Surname:____________________________
Date of Birth:_____________________ Contact Number:____________________
Membership Number:____________________
Are you at present taking any form of medication?______________________
If yes, give details:___________________________________________________________
_________________________________________________________________________
2. Do you smoke?
YES NO
If yes, how many?_______per day
3. Do you suffer from Asthma?
YES
NO
4. Do you suffer from Diabetes?
YES
NO
5. Do you suffer from, or have any family history of a heart
YES
NO
6. Are you know to have high or low blood pressure?
YES
NO
7. Have you recently felt discomfort or pain in your chest,
shoulders or upper back whilst being physically active?
YES
NO
8. Are you pregnant, or have you recently been pregnant?
YES
NO
9. Do you have any injury or condition which may be
aggravated by exercise?
YES
NO
10. Do you have a visual, hearing or mobility impairment?
YES
NO
complaint, coronary heart/vascular disease or stroke?
If you circled YES to any of the above, please provide details:
The Disability Discrimination Act 1995 defines a disability as a “physical or mental impairment
which has a substantial and long-term adverse effect on a person’s ability to carry out normal dryto-day activities”
Please provide the name, address and number of your doctor in the space below
DECLARATION AND AUTHORISATION
I confirm that the information given is a true and accurate statement. I understand that if I have
declared any of the conditions listed, further information may be requested.
Please be aware that it is your responsibility to inform us if there is a change to any of your
answers on the health screen.
Member Signature:
Date:
(For Office Use Only)
Further information requested
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Outcome
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No action required
Doctors letter requested
Once doctor’s letter is presented please copy and attach to form.
Staff Signature__________________________________________________________________
Print name_____________________________________________________________________