Step It Up - Boot Camp Sign Up

By signing up to Step It Up's 13 Week Boot Camp you're taking a step towards a healthier lifestyle and achieving your goals. Step It Up requires some information to ensure we can help you achieve those goals. Your information remains confidential within the company.

First Name:*

Last Name:*

Address:*

Street Number:*

Street Name:*

Suburb:*

Best Contact Number:*

Alternative Contact Number:

Email:*

Emergency Contact Name:*

Emergency Contact Number:*

Goals:

Weight loss
Improve my fitness
Build muscle
Increase muscle tone
Increase strength
Have more energy

Do you have any medical conditions that may prevent you exercising?*

Yes
No

Please check any true statements below so we can assess your health needs:

History

Heart attack

Heart surgery

Pacemaker

Heart valve disease

Heart failure

Heart transplantation

Congenital heart disease

Symptoms
Do you experience/take:

Chest discomfort with exertion

Unreasonable breathlessness

Dizziness, fainting or blackouts

Heart medication

Other Health Issues

You have musculoskeletal problems

Concerned about the safety of exercise

You take prescription medication

You are pregnant or may be pregnant

Cardiovascular Risk Factors

You are a man over 45

You are a woman over 55 or you are postmenopausal or have had a hysterectomy

You are a smoker or gave it up recently

Your blood pressure is greater than 140/99mmHg

You don't know your blood pressure

You take blood pressure medication

Your blood cholesterol level is >240mg/dl (or not above 5.5mmols per litre)

You don't know your blood cholesterol level

You have a close blood relative who has had a heart attack before

You are diabetic or take medication to control your blood sugar

You are physically inactive (ie. less then 30 mins of exercise at least 3x a week)

You have epilepsy

You have asthma

Before proceeding please read the following terms & conditions and participating in personal strength, fitness and conditioning training legal document. By proceeding (submit) you are agreeing to these terms.

I have read, understand and agree to the terms and conditions of this program

I understand the risks involved and I have read and agreed to the participating in personal strength, fitness and conditioning training legal document