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You have selected a Premium for 2 at a cost of £99.00 per month at the Ivybridge Leisure Centre (Devon) site.

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D.O.B

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Address 2

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Surveys

Please confirm by entering into the contract with us you agree to receiving communication regarding your accounts, subscriptions, and participating activities. You may receive service messages. Your data may be shared with third parties for agreed data processing such as the collection of subscription fees. Please refer to our privacy policy for more details. To read the privacy policy click here:

Step 2. Your details

Name:	Pal Kienitz	Edit
Email:	pal.kienitz@dcslsoftware.com
Mobile:	12345678

Title

First name

Surname

D.O.B

How did you hear about us?

Post code

Address

Address 2

Town

County

Telephone

Mobile

I will accept communication via:

Post

SMS

Social Media

Telephone

I wish to hear about the following items:

Centre Updates

Membership Information

Special Offers

Surveys

Your health

Set all to "Yes"
Set all to "No"

Has your doctor ever said you have any heart condition and that you should only do exercise/physical activity recommended by a doctor?

Yes No

Do you feel pain in your chest when you do exercise/physical activity?

Yes No

In the past month have you had chest pains when you were not doing exercise/physical activity?

Yes No

Do you lose balance because of dizziness or do you ever lose consciousness?

Yes No

Do you have a bone or joint/back problem which could be made worse by a change in your exercise/physical activity?

Yes No

Is your doctor currently prescribing medication for your blood pressure or heart condition?

Yes No

Any other significant illness, recent or serious operation?

Yes No

Do you know of any other reason why you should not exercise or do physical activity?

Yes No

"Yes" was selected for one of the options. By proceeding you confirm you have consulted with your doctor and are safe to join the gym

I confirm I do not confirm

ADULT#2 HEALTH

Set all to "Yes"
Set all to "No"

Has your doctor ever said you have any heart condition and that you should only do exercise/physical activity recommended by a doctor?

Yes No

Do you feel pain in your chest when you do exercise/physical activity?

Yes No

In the past month have you had chest pains when you were not doing exercise/physical activity?

Yes No

Do you lose balance because of dizziness or do you ever lose consciousness?

Yes No

Do you have a bone or joint/back problem which could be made worse by a change in your exercise/physical activity?

Yes No

Is your doctor currently prescribing medication for your blood pressure or heart condition?

Yes No

Any other significant illness, recent or serious operation?

Yes No

Do you know of any other reason why you should not exercise or do physical activity?

Yes No

"Yes" was selected for one of the options. By proceeding you confirm you have consulted with your doctor and are safe to join the gym

I confirm I do not confirm

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Step 3. Your health

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Step 2. Your details

ADULT#2 DETAILS

Your health

ADULT#2 HEALTH

Step 3. Your health

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