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MALL WALKING PROGRAM
Registration Form
Centre…………………………
Name:…………………………………..…………….. Date of Birth:…………………………
Address:………………………………………..…..… Suburb: ……………………… Postcode:…………
Daytime contact number:………….………. Alternative Contact Number:………………………….
Preferred name for badge…………………………
Emergency Contact
Name: ………………………..…………….. Relationship:…………………………..
Phone: (h)……………………………………(w)………………………………………
1. Have you discussed your involvement in this walking program with your doctor?
q Yes
q No. (if no, we recommend you see your doctor before commencing this program.)
2. Regular Doctor’s Name:……………………………..Doctor’s Phone………………..……
3. Your goals for participating in this program are:
q Lose weight q Increase fitness q Increase Flexibility
q Increase social contact q Prevent health problems q Other…………….
4. Do you have any of the following health conditions?
- Asthma
- High Blood Pressure
- Heart disease
- Diabetes
- Joint Problems (e.g. arthritis)
- Back problems
q Other: (please specify)____________________
5. How would you describe your current level of activity? (please tick þ appropriate box)
- No exercise
(eg. no regular walking or participation in classes).
- Small amount of regular activity
(e.g. walk for 30 minutes 1-2 times per week
- Regularly participate in some form of exercise
(e.g. walk for 30 minutes or more, 3 or more times per week, play a sport).
6. What size T-shirt do you normally wear?
q Medium q Large q Extra Large q Extra Extra Large
I understand that Mall Walking instructors intend to take all safety precautions possible, including calling an ambulance in a critical emergency, but cannot accept responsibility for loss or damage to personal property or personal injury. Accordingly, I release Adelaide Mall Walking from all liability which they would bear in relation to the loss or damage to personal property or personal injury to me, sustained through my participation in Mall Walking.
Signature of Client/Walker:……………………………………….Date:…………………...
The information contained in this form will be treated as private and confidential, to be released only to my own doctor or be identified if used for statistical purposes.
Office Use Only:
Data entered q Start Date: _______/_____/______ ID Number: ________
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