Fringe Sports Membership sign up

Personal Details

Fringe Membership Type *

First Name *

Surname *

Date of Birth *

Address *

Postcode *

Telephone Number

Mobile Number

Email Address *

Previous Member *

Yes
No

Promotional Code

Do you require a parking permit *

Yes
No

Car Reg *

Emergency Contact Details

Emergency Name *

Emergency Number *

Relationship *

Physical Activity Readiness

Please read the questions carefully and answer each one honestly. All answers will be treated with the strictest confidence

Do you have a heart condition?

Yes
No

Do you ever feel pain in your chest at any time or during physical activity?

Yes
No

Do you suffer from any bone or joint problems?

Yes
No

Do you ever lose balance or suffer from dizziness?

Yes
No

Do you currently have any injuriesYes

Yes
No

Are you currently taking any prescribed medication?

Yes
No

Are you diabetic?

Yes
No

Do you have any allergies?

Yes
No

Are you currently pregnant or have been pregnant in the past 6 months?

Yes
No

Do you know of any other reason why you should not do physical activity?Yes

Yes
No

physical issues

If you answered yes to any of the above questions, please consult your doctor before you begin to exercise.

If your health changes and you answer yes to any of the above, please inform sports staff immediately and consult your doctor before continuing to exercise.

Declaration

I declare all the above statements are true and to the best of my knowledge. I am aware that �� does not accept responsibility for personal injury caused from using the facilities or equipment. I have read, understood and completed all parts of this questionnaire. I understand that it is my responsibility to inform the instructor if my health status changes at any time. Any questions i had were answered to my satisfaction by a member of staff. *

*Once you click submit, you will be redirected to PayPal where you will need to make payment to complete your registration. If you do not complete the PayPal process, your registration will be void. If you are unable to complete your registration via PayPal, please submit your registration and contact events@qmu.ac.uk to arrange an alternative payment method.

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