Medical and assurance form – Adult – Aged 19 and over PRIVACY NOTICE In order to provide an effective service to our members, it is necessary for Pembrokeshire Weightlifting (known as Strength Academy Wales) to collect some personal information in this form. Information collected will be used for the purposes of the legitimate interests pursued by Pembrokeshire Weightlifting and data will be stored and protected in compliance with our legal obligations to meet GDPR standards.Name* Email* Date of birth* DD dash MM dash YYYY Gender* Male Female Prefer not to say Home Address* Street Address Address Line 2 City County / State / Region ZIP / Postal Code Contact phone number* 1. Please read and agree to the belowPlease read and agree to the below 1. You should not exercise beyond your own abilities. If you know or are concerned that you have a medical condition which might interfere with you exercising safely, before you use our equipment and facility you should seek advice from a relevant medical professional and follow that advice. 2. You should make yourself aware of any rules and instructions (displayed at the centre), including warning notices. Exercise carries its own risks. You should not carry out any activities which you have been told are not suitable for you. 3. You should inform us immediately if you feel ill when using our equipment or facility. 4. All opening times are coached. If you are not proficient in using our equipment or at lifting techniques you must seek advice from our coaches until you become competent and able to use our equipment safely and perform exercises with good technique 5. You confirm that you are able to exercise safely. 8. In an emergency you agree to receiving medication and any emergency treatment, as considered necessary by the medical authorities present. 9. You understand that activity images may be used for promotional purposes.I understand and agree to follow the above statements.* Tick box to sign 2. Medical conditionsDo you have any medical conditions that may affect you, during exercise activities?* Yes No If YES, please give brief details:Do you have any allergies (including allergy to medication):* Yes No If YES, please give brief details:Do you take any types of medication?* Yes No If YES, please give brief details:Have you had an illness, injury or accident that may affect you, during exercise activities?* Yes No If YES, please give brief details:Are there any other details you need to inform us about which may affect you exercising at our centre or with our activities?* Yes No If YES, please give brief details:Do you have a disability / impairment Manual Wheel Chair - self propelled Manual Wheel Chair - assisted Electric Wheel chair user Learning disability - moderate Learning disability - severe Visual impairment Hearing impairment Amputee Other physical disability Speech and language / communication difficulties Emergency contact detailsName* Relationship to you:* Contact phone number:* Doctor’s SurgeryName:* Telephone:* Address* Street Address Address Line 2 City County / State / Region ZIP / Postal Code
