ABN: 91 839 379 512

Peita Murphy - 0414 470 281

Renee Hagel - 0432 983 635
e: info@funkwellnessprojects.com.au
www.funkwellnessprojects.com.au

Date: _____ / _____ / _____

Mr / Mrs / Miss / Ms

Sex: M / F

D.O.B. _____ / _____ / _____

First Name : _______________________________

Surname: __________________________________

Address: __________________________________

Suburb: ____________________________________

State:_________________ P/Code: ____________

Phone: ____________________________________

Email: _________________________________________________________________________________
Occupation: _______________________________
Emergency Contact Name : ______________________________________ Ph: ______________________
How did you hear about us? _______________________________________________________________

Do you have or have you had any of the following:

Family history of heart attack?

Y/N Dizziness / fainting / blackouts?

Y/N

High blood pressure?

Y/N Are you pregnant?

Y/N

A major illness or surgery in the last 2 years?

Y/N Are you trying to conceive?

Y/N

Diabetes?

Y/N Do you take prescription medicine?

Y/N

Asthma / difficulty breathing?

Y/N Muscular skeletal problems?

Y/N

Do you smoke?

Y/N High cholesterol?

Y/N

Epilepsy?

Y/N Do you take any supplements?

Y/N

Arthritis / joint condition?

Y/N Heart disease or any other cardiovascular

Y/N

condition?

Do you have any injuries or joint problems, aches or pains (please provide details)?

Y/N

______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
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Funk Wellness Projects
Sunshine Coast & Brisbane North

ABN: 91 839 379 512

Peita Murphy - 0414 470 281
Renee Hagel - 0432 983 635
e: info@funkwellnessprojects.com.au
www.funkwellnessprojects.com.au

Please select the statements that most apply to you:

I need to get fitter

I need to look my best

I need more muscle tone

I want to lose fat

I need to build muscle

I need to get stronger

I need more energy

I have a sporting goal

I need a healthy eating plan

I want to feel confident about my body

I need to rehabilitate part of my body _________________

What exercise/s do you enjoy? ___________________________________________________________

What exercise/s dont you enjoy? _________________________________________________________

Goals
What would you like to achieve? __________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
When would you like to achieve it by? _____________________________________________________
_____________________________________________________________________________________
WHY do you want to achieve this goal? _____________________________________________________
_____________________________________________________________________________________
What do you need to do to achieve this goal? _______________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
How will you feel if you do achieve this goal? ________________________________________________
_____________________________________________________________________________________
How will you feel if you dont achieve this goal? ______________________________________________
_____________________________________________________________________________________

Training Commitment
How many days a week are you able to train? _______________________________________________
How much time each day are you able to train? ______________________________________________
Which time of day can you exercise? _______________________________________________________

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Funk Wellness Projects
Sunshine Coast & Brisbane North

ABN: 91 839 379 512

Peita Murphy - 0414 470 281
Renee Hagel - 0432 983 635
e: info@funkwellnessprojects.com.au
www.funkwellnessprojects.com.au

Preparation for Training & Adventures

Please come prepared for your session, dressed in comfortable activity clothing, wearing deodorant and
with a water bottle and towel. It is a good idea to avoid eating a large meal two hours prior to
exercising. Try to arrive at least five minutes before your scheduled appointment time, so that you can
warm up and/or prepare yourself for your session.

After your Session

Drink plenty of fluids and maintain a high water intake. Be sure to confirm your next training session
with me!
Cancellation Policy
If I am unable to keep an appointment for any reason and I am unable to give you at least 24 hours
notice, you will always receive a free training session. If you are unable to give me at least 12 hours
notice of cancellation I require you to make a normal payment. I thank you for your consideration.
Please be on time for your session if you arrive late the session must still finish on time.
Waiver
WARNING: THIS IS A LEGAL DOCUMENT THAT AFFECTS YOUR RIGHTS
Agreement for Participating in Personal/Group Strength, Fitness and Conditioning Training, Boot
Camps and Wellness Projects (Outdoor Adventures).
The Trainer refers to the Australian Registered Business Funk Wellness Projects. The Activity refers
to the participation in personal/group strength, fitness and conditioning training, boot camps, outdoor
adventure events and general advices.

I acknowledge that it is a condition of participating in this activity that I do so at my own risk.

I accept all risks and hereby indemnify and release the trainer, their agents, affiliates, employees,
members, sponsors, promoters and any person or body directly and indirectly associated with
the Trainer, against all liability (including liability for their negligence and the negligence of
others) claims, demands, and proceedings arising out of or connected with my participation in
this activity.
This release and indemnity continues forever and binds my heirs, successors, executors, personal
representatives and assigns.
I acknowledge that participating in this activity may involve a risk of serious injury or even death
from various causes including: over exertion, dehydration, equipment failure and accidents with
equipment and surroundings.
I recognise the difficulties associated with the activity and attest I am physically fit to participate
safely in the activity and that a qualified medical practitioner has not advised me otherwise.

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Funk Wellness Projects
Sunshine Coast & Brisbane North

ABN: 91 839 379 512

Peita Murphy - 0414 470 281
Renee Hagel - 0432 983 635
e: info@funkwellnessprojects.com.au
www.funkwellnessprojects.com.au

I understand the demanding physical nature of this activity. I am not aware of any medical
condition, injury or impairment that will be detrimental to my health if I participate in this
activity. In the event that I become aware of any medical condition, injury or impairment that
may be detrimental to my health if I participate in this activity my Trainer will be immediately
informed. By continuing to participate in this activity, I accept the risks despite these conditions
and am still, and will always be under the terms of this agreement.
I certify that I am 18 years or older and have read this document and fully understand it; OR
As a parent or guardian of the participant (a) I agree to the above for myself and on behalf of the
participant and (b) I indemnify and will keep indemnified any person or body directly or indirectly
associated with the conduct of the activity on the terms referred to.

Signature: _________________________________ (Guardian/parent to sign if under 18 years of age)

Print Name: ___________________________________________________________________________
Date: _____ / _____ / _____
Trainers Signature: _____________________________________________________________________
Name of Trainer/s: _____________________________________________________________________

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Funk Wellness Projects
Sunshine Coast & Brisbane North