Name *

First Name

Last Name

Your Phone Number *

(###)

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Date of birth *

MM

DD

YYYY

Emergency Contact *

First Name

Last Name

Emergency Contact Number *

(###)

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Medical - Tick yes if any apply to you *

High Blood Pressure Allergies High Cholesterol Back, joint or muscle disorder Surgery or Chronic Disease Diabetes Incidents of blackout/fainting Respiratory disease Pregnancy within the last three months Smoking habit Family history of Heart Disease 2-3 stone overweight Photosensitive Epilepsy and seizures Any other serious medical issues we should know about.

Yes - If so please email Coach Daragh prior to commencing training

No