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					                                                                                                                                                  Hello
Club                                                                                                                                              There No.
Guest Name
& Surname                                                                                                                                         ID Number

Age                                                           Date of                                                         Male                          Tel (H)
                                                              Birth                        /           /                      Female
                                                                                                                                                            Tel (W)
Address
                                                                                                                                                            Cell

Employer                                                                                                   Occupation                                                                                                                                              HELLO THERE
E-mail                                                                                                     Medical Aid                                                      Loyalty                                                            A                                               2005/041060/07
Address                                                                                                                                                                     Programme
Reason for                                                                                                                                                                                                                                       OBJECTIVES: PLEASE ( )
                              Workout                       Tour of Facility                         Spectator                       Other:
Visit
                                                                                                                                                                                                                                                 Lose Weight                            Build Muscle
I agree that I enter and exit the premises, including the parking areas, and use the equipment and facilities at my own risk and subject to the terms and conditions
set out below. I agree that Virgin Active South Africa Group (Pty) Ltd, Virgin Active South Africa (Pty) Ltd, Virgin Active 1993 (Pty) Ltd (the “Virgin Active
Companies”) and their directors, officers, employees, representatives, agents and independent contractors and other members (“other Protected Parties”) will                                                                                     Increase Fitness                               Meet People
not be liable for death, injury, loss or damage suffered by me and/or my dependants. I agree that the Virgin Active Companies and the other Protected Parties
shall not be liable for any loss or damage suffered by me and/or my dependants as a result of theft on the part of the Virgin Active Companies’ independent                                                                                      Personal Training                                Swimming
contractors, consultants, or other member(s).

I and/or my estate hereby indemnify/ies each of the Virgin Active Companies and the other Protected Parties against any claim by any person, including any                                                                                       Tone                  Stress Release/Relaxation
minor child(ren) accompanying me, arising directly from my death, injury, loss or damage suffered or which arise from the death, injury, loss or damage suffered
by a member, allegedly caused or contributed to by an act or omission by a member of the Virgin Active Companies and other Protected Parties.”                                                                                                   Other:
                                                                                                                                                                                                                                                 CURRENT ACTIVITIES: PLEASE ( )
Signed at .......................................................................... on the ...................................day of ................................................................20..............                           None                 Swimming                        Squash
                                                                     ..............................................................................................                                                                              Aerobics                     Running                     Spinning
Assisted by Legal Guardian                                                                           Guest (Signature)
                                                                                                                                                                                                                                                 Weights                    Other:

............................................................................. ........................................................................... ..................................................................................     HOW DID YOU HEAR ABOUT VIRGIN
           Legal Guardian (Signature)                                          Legal Guardian (Print Name & Surname)                                                                      Capacity                                               ACTIVE: PLEASE ( )

JUNIOR GUESTS:                                                                                                                                                                                                                                   Billboards                     Press Adverts                             Flyers
7-13 years, please fill in the details in the space provided below and complete 7-13 year PAR Q on reverse.
                                                                                                                                                                                                                                                 Sign on Buildings                              Posters                      Radio
14 years and older, please complete separate Hello There.                                             Reason for Visit
                                              Dependant Name & Surname                                                                                          Age
                                                                                                                                                                                 *
                                                                                                                                                                               ( )Subject to age restrictions.
                                                                                                                                                                                 Physical Activity
                                                                                                                                                                                                                                                 Online                Fitness News                               Television

1                                                                                                                                                                                Junior Care/Spectator
                                                                                                                                                                                                                                                 Word of Mouth                             Other:

                                                                                                                                                                                 Physical Activity                                               Referred by:
2                                                                                                                                                                                Junior Care/Spectator                                           Have you been or are you a member of any
                                                                                                                                                                                 Physical Activity
3                                                                                                                                                                                Junior Care/Spectator
                                                                                                                                                                                                                                                 health and fitness facility?

FOR CLUB                       Receptionist                                                                          Receipt
USE ONLY:                      Print Name                                                                            Number
                                                                                                                                                                                      Voucher                                                   MC


                             PAR Q (Physical Activity Readiness Questionnaire)                                                                                                                                                                 B
                                                                                                                                                                                                                                               NOTE: Based on the PAR Q Feedback, you
PLEASE ( ) THE BOXES BASED ON THE QUESTIONS BELOW.                                                                                                                                                                     YES           NO
                                                                                                                                                                                                                                               m a y r e q u i r e d o c t o r ’s c l e a r a n c e b e f o r e
Has your doctor ever told you that you have heart trouble?                                                                                                                                                                                     exercising. It is the responsibility of the
                                                                                                                                                                                                                                               guest to inform Virgin Active of any change
Do you currently suffer from diabetes?                                                                                                                                                                                                         to his/her health.

Have you had pains in your heart and chest?
                                                                                                                                                                                                                                                Doctor’s Name:
Do you at times feel faint or have spells of severe dizziness?

Do you have asthma, emphysema or bronchitis?                                                                                                                                                                                                     ........................................................................................................

Do you currently have thyroid problems?

Have you had any of the following:                                                                                                                                                                                                               ........................................................................................................

• Shortness of breath

• Heart palpitations                                                                                                                                                                                                                            Tel. No.: ........................................................................................
• Peripheral Vascular Disease (Inflammation in veins)

• Leg cramp during walking                                                                                                                                                                                                                      Guest’s Next of Kin: ................................................................

• Persistent swelling
                                                                                                                                                                                                                                                 ........................................................................................................
Are you pregnant?

Are you male and 55 or older OR female and 65 or older?
                                                                                                                                                                                                                                                Tel. No.: ........................................................................................
Has your doctor ever said that your blood pressure was too high?

Have your parents, brothers or sisters suffered from heart disease before the age of 55?
                                                                                                                                                                                                                                                Witness Name:
Are you currently a cigarette smoker or have you smoked within the the last six months?
                                                                                                                                                                                                                                                 ........................................................................................................
Has your doctor ever told you that your cholesterol level is too high?

Do you do less than 3 hrs of physical activity per week (housework, gardening, walking, etc.)?
                                                                                                                                                                                                                                                Signature: ...................................................................................
Has your doctor ever told you that you suffer from bone or joint problems, such as arthritis,
that have been aggravated or might be made worse with exercise?                                                                                                                                                                                FOR CLUB
                                                                                                                                                                                                                                                                                    LOW                  MODERATE                             HIGH
                                                                                                                                                                                                                                               USE ONLY:
                                                                                                                Junior Health Risk Screening (7-13 years)
                                                                                                                                                                                                                                    Child 1 Child 2 Child 3
Me Details                                                                                                                                                Brain ’n Muscles
                    Child 1                                        Child 2                                      Child 3                                   1. Does your child have, or has your child had difficulty/problems with any of the following:

Name:               ............................................   .......................................      .......................................   • Vision                                                                      .......................................
                                                                                                                                                          • Hearing                                                                     .......................................
Date of Birth:                 /         /                                  /         /                                /         /                        • Speech/language                                                             .......................................
                                                                                                                                                          • Poor balance/instability                                                    .......................................
Gender:                 Male                 Female                    Male                Female                 Male                Female              • Motor sensory skills                                                        .......................................

Please ( ) all relevant blocks                                                                           Child 1           Child 2       Child 3          2. Has your child ever had a spinal or brain injury?

My Family History (not to be confused with Me History)                                                                                                    ‘Special’ Conditions
1. Does your child have a family history (parents or siblings) of heart or metabolic                                                                      1. Does your child have any chronic disability or illness?
   disease?                                                                                                                                               2. Are you aware of any medical reason/condition that might
                                                                                                                                                             prevent your child from participating in an exercise
• High Cholesterol                                                   ........................................                                                programme?
• High Blood Pressure                                                ........................................
                                                                                                                                                          If Yes, please explain: .........................................................................................................................
• Stroke                                                             ........................................
• Diabetes Mellitus (Type I or II)                                   ........................................
• Cancer                                                             ........................................
                                                                                                                                                          ............................................................................................................................................................
• Cardiac Condition                                                  ........................................                                             3. Is your child taking prescribed medication?
If Yes, please state which relative, and what age                                                                                                         If Yes, please give details: ...................................................................................................................
   Father       < 55 years
   Brother      < 55 years                                                                                                                                ............................................................................................................................................................
   Mother       < 65 years                                                                                                                                4. Does your child have, or has your child had an eating
   Sister       < 65 years                                                                                                                                    disorder?

Me History                                                                                                                                                How Active Am I?
1. Has your child ever suffered any heart, respiratory or metabolic condition?                                                                            1. Current Physical Activity Levels: Please tick the most appropriate description of your
                                                                                                                                                             child’s current level of physical fitness?
• High Cholesterol                                                   ........................................
• High Blood Pressure                                                ........................................                                             • Poor                                                                        .......................................
• Asthma                                                             ........................................                                             • Fair                                                                        .......................................
• Obesity                                                            ........................................                                             • Acceptable                                                                  .......................................
• Epilepsy                                                           ........................................                                             • Good                                                                        .......................................
• Hear t Disease                                                     ........................................                                             • Excellent                                                                   .......................................
• Cystic Fibrosis (Lung Disease)                                     ........................................
                                                                                                                                                          2. Physical Activity Status: Over the past 3 months I would describe my child as having
2. Does your child currently experience any symptoms of respiratory or cardiovascular                                                                        been (an exercise session consists of 20-30 minutes of exercise)
   disease?
                                                                                                                                                          • Inactive
• Frequent wheezing/coughing                                         ........................................                                             • Occasionally active              -    “at least 1-4 sessions per month”
• Chest pain                                                         ........................................                                             • Somewhat active                  -    “at least 1-2 sessions per week”
• Frequent fainting or dizzy spells                                  ........................................                                             • Reasonably active                -    “at least 2-3 sessions per week”
• Shor tness of breath                                               ........................................                                             • Active                           -    “at least 3-4 sessions per week”
• Unusual fatigue with usual activities                              ........................................                                             • Very active                      -    “more than 4 sessions per week”
• Increased bleeding tendency/haemophilia                            ........................................
                                                                                                                                                          5. Please select activities you are comfortable for your child to participate in
Bones ’n Joints
                                                                                                                                                          • Outdoor Activities                                                          .......................................
1. Does your child currently suffer from any symptoms of joint disease such
                                                                                                                                                          • Face Painting                                                               .......................................
   as the following?
                                                                                                                                                          • Swimming                                                                    .......................................
                                                                                                                                                          • My child can swim 25 metres without the
• Muscle injur y/disease                                             ........................................                                               issue of buoyancy aid?                                                      .......................................
• Tendon injury/disease                                              ........................................
• Bone injury/disease                                                ........................................                                             Mom or Dad say YES...or NO
• Swelling                                                           ........................................
• Stiffness                                                          ........................................                                             I hereby acknowledge that:
• Osteo-ar thritis                                                   ........................................
• Rheumatoid ar thritis                                              ........................................                                                 The information above regarding my child’s/children’s health, is to the best of my
                                                                                                                                                          knowledge, correct
Please ( ) tick which joint/body area has been affected:
                                                                                                                                                               I will inform the.............................................Virgin Active immediately if there are any changes
• Neck                                                               ........................................                                             to the information provided
• Shoulder                                                           ........................................
• Elbow                                                              ........................................
• Wrist/hand                                                         ........................................                                             Parent/Legal Guardian Signature ............................................................... Date...............................
• Lower Back (lumbar spine)                                          ........................................
• Hip                                                                ........................................                                                                                    Child 1                    Low                           Moderate                            High
• Knee                                                               ........................................                                               FOR CLUB
                                                                                                                                                                                                 Child 2                    Low                           Moderate                            High
• Ankle                                                              ........................................                                               USE ONLY:                            Child 3                    Low                           Moderate                            High
• Foot/toes                                                          ........................................


    Recommendation

    It appears that you and/or your dependant(s) have some current healtlh hiccups and we would like to recommend that you and/or your dependant(s) follow a prescribed training
    programme where the type and intensity of the workout is tailored for you and/or your dependants specifically.

    We recommend that you liaise with a physician, or one of our appointed Biokineticist, for some guidelines before you and/or your dependant(s) start an exercise programme. At Virgin
    Active we subscribe to the guidelines laid down by the American College of Sports Medicine to ensure that you and/or your dependant(s) safety is our number one priority.

    Kindly note that it is your responsibility to act on our above-mentioned suggestion. We’d like to remind you that failure to adhere to our recommendation might place you and/or your
    dependant(s) physical well-being at risk.

    Assumption of Risk

    Please read this together with the “No Liability and Indemnity section” appearing on the front of the Hello There Card that you have signed.

    Knowing the risk described above and your recommendation, I and/or my dependant(s) hereby agree to release and indemnify Virgin Active, it’s directors, employees, contractors or
    dependant contractors from and against any claim which I, in my personal capacity and/or my capacity as legal guardian of my dependant(s), and/or my capacity as guardian of any
    minor children placed under my charge may have for any losses, damages or injuries arising out of or in any connection with any participation in any exercise routine and/or
    programme and/or class offered by Virgin Active.

    By my signature below I confirm that I have carefully read this release and acknowledge that I understand it.


    Signature of Guest:........................................................................................................ Date: ......................................


    Signature of Legal Guardian:......................................................................................... Date:......................................
    (If guest is a minor)
Date   Comments

				
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posted:2/15/2011
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