screening

form

Thanks for choosing to start your journey with HCC.
Complete the form below as best you can, please do not leave any information out as this may be vital .

If you are unsure contact us so we can go over it and help you get started .

Nga mihi

 

Please complete the form below

Date of birth *
Date of birth
Introduce yourself and let us know which training group you would like to join.
Please give us an indication of what you want to achieve.
Have you ever been diagnosed for or suffered from any of the following conditions :
What is your current level of fitness? *
1 being little to no physical activity and 5 being very active with a good level of fitness
Disclaimer
I agree to participating in HCC's programme and understand this programme involves activities that are constantly varied and can be strenuous. I accept any and all liability for any loss, damage, expense or injury including death that I or that my next of kin may suffer, now or in the future as a result of my participation in this programme. I understand that my personal information is confidential and may be used for research purposes and will be held in accordance with the Health and Privacy Act. I understand that no material that could identify me will be used in any reports within the research anomy records will be destroyed after ten years. I understand that HCC will not sell or release my personal information. I confirm that i am eighteen (18) years of age and i have read, understood and agree to the above conditions in this agreement prior to signing. *