Adult Gym membership Form

Please complete this form to join our membership. On receipt of this form, a member of staff will be in touch to arrange a start up plan with you.

First name

Last name

Birthday

Day

Month

Year

Postcode

Email

Phone

Address

Emergency contact First name

Emergency contact Last name

Emergency contact Phone number

Which Doctors surgery are you registered with?

Do you attend other groups within The Hub? If so, which group?

High cholesterol

Yes

No

Have you ever suffered from high cholesterol?

Heart disease

Yes

No

Is ther any history of hear disease or heart trouble in the family?

Asthma

Yes

No

Do you suffer from asthma?

Surgeries

Yes

No

Have you had any surgeries in the past 3 years or attended hospital?

Muscles & ligaments

Yes

No

Do you suffer from any muscle or ligament problems?

Joint paint

Yes

No

Do you suffer from any knee or back pain?

Fainting

Yes

No

Have you ever felt faint or had spells of dizziness?

Epilepsy or diabetes

Yes

No

Have you ever been diagnosed with epilepsy or diabetes?

Pregnancy

Yes

No

Are you pregnant or post-natal?

Is there any reason you have been advised not to participate in physical activity?

Are you currently taking any medication? If so, please specify the reason.

Are you allergic to anything? If so, please provide details.

Is there any other information we should be made aware of?

Photography consent

Yes

No

I give permission for my image to be taken during my time in the fitness suite and used by West Calder Hub for the following purposes: Display in the Community Centre or on The Hub’s website or social media platforms. Use in The Hub’s promotional materials. I acknowledge that I have the right to access and review the photos taken of me and request their removal if I am not satisfied with their use. I understand that I have the right to withdraw my consent at any time by contacting The Hub in wri

On receipt of your application, we will send you details on joining instructions and payment details.