Name *

First Name

Last Name

Phone

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Are you experiencing one or more of the following COVID-19 symptoms: high temperature, continuous cough, loss of smell or taste? *

Yes

No

Have you ever suffered with epilepsy? *

Yes

No

Are you pregnant? If yes, how many months? *

Yes

No

Have you ever suffered from heart trouble? *

Yes

No

Are you presently taking any form of medication? *

Yes

No

Do you suffer from chest pains? *

Yes

No

Do you ever have spells of dizziness or feel faint? *

Yes

No

Have you ever had either high or low blood pressure, and/or high cholesterol? *

Yes

No

Have you ever had asthma, chronic bronchitis or any other chest ailments? *

Yes

No

Do you suffer from severe back pains or any other orthopaedic problem? *

Yes

No

Do you suffer from severe headaches or migraines? *

Yes

No

Are you recovering from a recent illness / operation or injury? *

Yes

No

Have you any medical conditions that we should be aware of? *

Yes

No

Is there any history of heart disease in your immediate family (before age 55)?

Yes

No

Disclaimer *

PLEASE NOTE: If you have answered YES to any of the medical questions , you are advised to seek medical advice/approval before taking part in this programme. I have been informed that if I answer YES to any of the medical questions above I should seek medical advice/approval before commencing this class. If I wish to continue without such advice I do so entirely at my own risk. I confirm that I have read, fully understood and answered each question honestly. I understand the nature of the course and confirm that I am in appropriate physical and mental condition to participate. If at any time I have questions, feel unsafe or unwell I will immediately inform the Run Leader (or their assistant) and discontinue further participation. I understand that neither the Run Leaders or Barnsley Harriers can be held responsible for any injuries or ill health of any kind arising from participation.

Accept

I agree to my personal contact information being used to send me important class updates *

IMPORTANT: If you don’t tick this box it will not be possible to let you know about changes to the programme, cancellations etc. You can unsubscribe at any time.

Yes

No

I agree to my personal contact information being used to send me important updates and any other relevant updates from Barnsley Harriers. *

Yes

No