Health Declaration Form

top of page

Empowering You Through Dance and Movement

Home
About
Book a Class
Buy a Package
All Services
Rates
Member Only
- Handbook
- Loyalty
Shop
- Gift Card
More

Use tab to navigate through the menu items.

Health Declaration Form

Please fill out the following health declaration form in order to participate in our activity.

Full Name

Date

Phone

IC/ Passport Number:

Please tick if you have ever experienced the following:

Diabetes

Chest pain brought on by physical exertion

Epilepsy

Dizziness or Fainting

A bone, joint, or muscular problem or arthritis

Asthma or other respiratory problems

Any sustained injuries or illnesses

Any allergies e.g metal, medication, skin allergies etc

Are you taking any medication

Family history of heart problems

Have been admitted in hospital over the last 6 months

None of the above

Are you pregnant or have been in the last 6 months? *

Yes

Is there any reason not mentioned above why any type of physical activity may not be suitable for you? *

Yes

I understand that:

Bruises may occur due to the nature of the fitness

For my safety, physical spotting will occur during the classes

If the instructor requires further information about my illness or disability to be included in the activities, I will endeavour to make sure this information is available to him/her.

Pictures may be taken by the instructor during the class for social media purposes

By checkng this box, I acknowledge that I have read and agree to the Terms and Conditions

By checking this box, I affirm that I agree to the Release and Waiver of Liability

Your Signature

Thanks for submitting!

2nd Floor, Sky Arena, Jalan Penampang Baru, 89500 Kota Kinabalu, Sabah, Malaysia

+60 143583993

bottom of page