Full Name

The name that you use for official purposes, such as your passport or ID card.

Date Of Birth

This information is used to calculate your age and risk factors for certain health conditions.

Address

This information is used to contact you and provide you with relevant health services in your area.

Tel No.

This information is used to communicate with you and send you reminders or notifications.

Email

This information is used to register you for the lessons you choose at Kewi Learning Centre and send you confirmation, feedback and updates.

Emergency Tel:

The number where you or your guardian can be contacted in case of an emergency during the lessons.

Emergency Name

The name of the person who can be contacted in case of an emergency during the lessons.

Class

The name of the lesson or class that you want to sign up for at Kewi Learning Centre.

Please read the following questions carefully and answer yes or no.

Do you suffer from any heart conditions?

Yes

No

Do you feel any pains in your chest when doing physical activities?

Yes

No

Do you often feel faint or have dizziness?

Yes

No

Have you suffered from any recent injury?

Yes

No

Has your Doctor ever told you that you suffer from bones or joints problems?

E.g (Arthritis)

Yes

No

Do you have any of the following conditions?

Asthma

Yes

No

Epilepsy

Yes

No

Muscle problems

Yes

No

Back problems

Yes

No

Diabetes

Yes

No

Do you smoke?

Yes

No

Do you take any prescribed medication?

Yes

No

Is there anything else regarding your medical condition that you need to disclose?

Yes

No

Tell us about it

Have you participated in any form of physical exercise before?

E.g Football training, Fitness work outs, dance etc

Yes

No

How did you hear about us?

Disclaimer of liability, injuries of all types can occur when participating in physical activities, fitness and training programs, therefore KEWI encourages all members to pursue physical examination by a licensed physician prior to undertaking etc. Stop exercising if you suddenly feel unwell like dizziness, lightheaded, headaches, nausea, pains in the chest etc. Please report to the trainer immediately. Kewi Learning Centre disclaims any liability for incidental or consequential damages and assumes no liability or responsibility for any loss, injury or damage suffered by any person as a result of the use or misuse of any information.

I have read and understood the disclaimer

Submission Date

Are you human?

Health Assessment Form

Please read the following questions carefully and answer yes or no.

Do you have any of the following conditions?

Address:

Phone:

Email: