Under 16 Gym Membership Form

Please complete this form to join our under 16 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

Date of Birth

Day

Month

Year

Postcode:

Email:

Contract phone number:

Emergency contact name:

Emergency contact number:

Which Doctors surgery are you registered with?

Accompanying Adult Details:

This is the adult who has valid West Calder Hub Gym membership and will be with the young person at all the times whilst they are within and using the fitness suite.

First Name

Last Name

Email

Phone Number

High cholesterol:

Yes

No

Have you ever suffered from high cholesterol?

Heart disease:

Yes

No

Is there any history of heart 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?

High blood pressure:

Yes

No

Do you have a history of high blood pressure?

Back pain:

Yes

No

Do you suffer from any knee or back pain?

Joint pain:

Option 1

Option 2

Do you suffer from any knee or back pain?

Muscles & ligaments:

Yes

No

Do you suffer from any muscle or ligament problems?

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?

Is there any reason you’ve 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 confirm that I, as the adult gym membership holder, will

1. Take full responsibility for the Safety & Supervision of the Under 16 gym member assigned to my membership

2. Be present at the induction to countersign the induction paperwork

3. Produce a valid access card on entry to The Hub and sign myself and the Under 16 member in and out at reception

Signature of Parent/Guardian/Adult Gym Member

Date