HL Registration Form 2025 by marcedwards | Jan 8, 2025 | Uncategorized Training – Sign in / Disclaimer 2023 Lifestyle Questionnaire and PARQ for UTA and Associated parties Name* First Last Address* Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* Date of Birth* DD slash MM slash YYYY Next of Kin Name* Next of Kin Contact Number* Doctor Name* Doctor Surgery / Contact* Do you suffer / Have you suffered from any of the following? Rheumatoid or Osteo Arthritis Head / Neck Injury Shoulder/Arm/Wrist/Hand Injury Back Pain / Injury Hip / Pelvis Injury Do you suffer / Have you suffered from any of the following? Knee / Thigh / Leg Injury Ankle / Foot Injury Nerve Damage Swollen Joints Fractured Bones Do you suffer / Have you suffered from any of the following? Heart Problems Diabetes Epilepsy Early menopause Cancer If You answered yes above, please provide detailsAre you currently recieving treatment for anything? Yes No Have you had major surgery in the last 10 years? Yes No Have you had minor surgery in the last 2 years? Yes No If you answered yes to the above, please provide detailsDo you suffer / have you suffered OR have you ever had a medical consultation for any of the following conditions?AsthmaEpilepsyHigh / Low Blood PressureHeart Conditions / ProblemsChest PainsIf You answered yes above, please provide detailsAny other health issues not already mentioned, please list here:Are you pregnant? Yes No Have you ever been diagnosed with a learning disability / have any problems learning in school / require any special provision for assessments because of learning issues?* Yes No I understand that certain elements of the Session/Course can be physically demanding. I accept full & complete responsibility for my participation in the practical elements of this session/course* Yes I agree that The Company & ANY Representatives' are free of any/all liability of injury or health problem that may result from/be aggravated by my participation* Yes I agree that The Company & ANY Representatives' are free of any/all liability for death, injury or health problem that may result from/be aggravated by this training with 3rd parties* Yes I understand that by signing this / completing this form that any use of excersises post course/workshop/session, I assume all responsibility for demonstrations and the safety of the end user* Yes Is this submission for a *Course *Workshop *Seminar *Fitness Class *Personal Training? If so, Which is it and please select the course/class name. For example: Fitness Class – Kickboxing*Diploma in Personal Training – NVQDiploma in Personal Training – NVQ MentorshipDiploma in KickboxingLevel 2 Award in Kettlebell TrainingLevel 2 Award in Circuit TrainingLevel 2 Award in Suspension TrainingLevel 2 Award in Olympic Weight LiftingLevel 3 Award in Pre & Post Natal Prog DesignCPD in Developing FlexibilityCPD in Core ConditioningCPD in Fat Loss StrategiesOtherIf you selected Other above, Please give detail here: The Company and Representatives means anybody delivering a training session / Course / Workshop in association with / on behalf of Universal Training LTD or Associated Training Provider (Accredited or not) and any Training Session/Course/Class/Workshops.
