Aquanatal Booking Form

							AQUANATAL (NON-MEMBER) CLASS BOOKING FORM


Please fill in the form below and return to Blooming Babies, Tower Bank, Margaret Avenue, Bardsey,
Leeds, LS17 9AT along with a cheque made payable to Blooming Babies for £35.00 per course of 5
aquanatal classes.

Class dates and venues can be found at www.bloomingbabiesyorkshire.co.uk or by contacting Annie
at yorkshirebloomingbabies@gmail.com or on 07580004021.



Fields marked with an * must be filled in. Your telephone number is only if we need to contact you
about your booking – it is not used for sales or marketing purposes.

Thank you

Class*:

Date*:

Venue*:

Name*:

Estimated Due Date*:

Address*:



Telephone*:

Mobile*:

Email*:

How did you hear about this course?

Terms and conditions*:        I agree to the class terms & conditions

Signed:


If you have any queries about this form then please let us know and we’d be happy to help.

Please read our class terms and conditions over before placing a booking.
AQUANTAL (MEMBER) CLASS BOOKING FORM


Please fill in the form below and return to Blooming Babies, Tower Bank, Margaret Avenue, Bardsey,
Leeds, LS17 9AT along with a cheque made payable to Blooming Babies for £20.00 per course of 5
aquanatal classes.

Class dates and venues can be found at www.bloomingbabiesyorkshire.co.uk or by contacting Annie
at yorkshirebloomingbabies@gmail.com or on 07580004021.



Fields marked with an * must be filled in. Your telephone number is only if we need to contact you
about your booking – it is not used for sales or marketing purposes.

Thank you

Class*:

Date*:

Venue*:

Name*:

Estimated Due Date*:

Address*:



Telephone*:

Mobile*:

Email*:

How did you hear about this course?

Terms and conditions*:        I agree to the class terms & conditions

Signed:


If you have any queries about this form then please let us know and we’d be happy to help.

Please read our class terms and conditions over before placing a booking.
WATER FITNESS SCREENING & INFORMED CONSENT QUESTIONAIRE
NAME: ____________________________________________ D.O.B. __/__/__

ADDRESS: __________________________________________________________

EMERGENCY CONTACT NAME & TELE: ___________________________________

DOCTOR’S NAME & TELE: ______________________________________________

GENERAL INFORMATION:

Have you ever had heart trouble?                                                    Yes/No

Do you ever have heart/chest pains?                                                 Yes/No

Do you ever feel faint or have dizzy spells?                                        Yes/No

Do you suffer with Asthma?                                                          Yes/No

Has your Blood pressure ever been too high/too low?                                 Yes/No

Do you have any joint or bone problems that might be aggravated by exercise? Yes/No

Are you on any form of medication?                                          Yes/No
If yes, please state condition & medication: ____________________________________

PREGNANCY/DELVERY DETAILS:

How many weeks pregnant are you? __________________________________________

Has your Midwife/Doctor informed you of any pregnancy complications such as Low lying
Placenta; pre-eclampsia; high blood pressure; 3 or more consecutive miscarriages, etc.
If yes, please state: _________________________________________________________

If delivered, what is the date of delivery? __/__/__ What type of delivery did you have?

Please state any complications? ______________________

Have you been told by your Midwife/ Doctor not to exercise?                          Yes/No

NB: If you are still experiencing bleeding it is not appropriate to attend a water based exercise class.

Are you confident in the water?                                                      Yes/No

Are you currently exercising?                                                        Yes/No

Are there any other concerns regarding attending Aquanatal?                           Yes/No

I confirm I have completed this form honestly and hereby acknowledge that the nature of the exercise class I am
about to undertake has been fully explained. I will inform the Midwife/Instructor of any changes to the above.
Whilst I am aware that all care will be taken, I take part at my own risk.

Signed: __________________________________            Dated: __/__/__