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RETREAT BOOKING

RETREAT BOOKING FORM

please use the form below to register for our health retreat

Booking Form

First Name:

Last Name:

Phone:

Email:

Date Of Birth:

a. Room Type

b. If Twin or Double, Name Of Guest Sharing

Do You Have Any Special Or Dietary Requirements?:

1. Do you have a history of heart problems?

Yes

No

2. Do you have a history of lung problems?

Yes

No

3. Have you had chest pains or tightness in the chest?

Yes

No

4. Do you suffer from exercise induced asthma or other respiritory problems?

Yes

No

5. Do you suffer from headaches/ fainting/ dizziness?

Yes

No

6. Do you have pain/limited movement in any joint that could be made worse by a change in your physical activity?

Yes

No

7. Do you have diabetes?

Yes

No

8. Do you have epilepsy?

Yes

No

9. Have you had a recent operation/ chronic illness/ injury?

Yes

No

10. Are you pregnant/post natal?

Yes

No

11. Do you know of any reason why you should not do physical activity?

Yes

No

12. Is there a history of heart problems in your family?

Yes

No

13. Do you have high blood pressure?

Yes

No

14. Do you have a back problem that could be made worse by a change in your physical activity?

Yes

No

15a. Are you currently taking any medication?

Yes

No

15b. If YES give details

16. Emergency Contact:

DECLARATION: I am aware of and understand the potential risks associated with physical exercise and I am voluntarily partaking in these activities with knowledge thereof. I am aware activities are optional and as such I am voluntarily participating based on my health and ability. The health questionnaire has been completed to the best of my knowledge and belief. I understand that if there is a change in my condition at all, I must inform The Fitness Suite. Without prejudice to the above, The Fitness Suite will accept no liability for the loss or damage of whatsoever nature and howsoever arising caused to me or suffered by me whilst at the retreat, unless such loss or liability is caused by negligence. I have read and agree to be bound by the terms and conditions.

I agree

Thank you for contacting us.
We will get back to you as soon as possible.

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FIRST NAME

LAST NAME

EMAIL

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Where To Find Us

South Lane, Elland, HX5 0PA, United Kingdom

T: 01422 485710

E: info@thefitnesssuiteelland.co.uk

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All Rights Reserved | The Fitness Suite LTD

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