Sign In Form / Disclaimer | Universal Training Academy

Name*

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Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Phone*

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Date of Birth*

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 details

Are you currently recieving treatment for anything?

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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 details

Do you suffer / have you suffered OR have you ever had a medical consultation for any of the following conditions?

If You answered yes above, please provide details

Any other health issues not already mentioned, please list here:

Are you pregnant?

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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 - Circuit Training*

If 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 CoachingAcademy.Education (a trading name of Universal Training Academy LTD) or Associated Training Provider (REPs Accredited or not) and any Training Session/Course/Class/Workshops.