Participant Name
First Name
Last Name
Participant DOB (DD-MM-YYYY)
Sex
How old was your child as at 1st January this year?
Parent/Guardian Name
Email
Home Address
Mobile Number
Has a GP or specialist referred your child?
Doctors Name
Doctors Contact Number
Emergency Contact Name
Emergency Contact Number
Program Goals
1. Does your child have, or has your child had:
1.1. Please Specify
2. Does your child experience or has your child ever experienced:
2.1. Please Specify
3. Does your child have, or has your child had, an eating disorder?
4. Does Your child take any medications for (please name):
4.1. Please Specify
4.2. If your child is taking any medication, please state if there are any side effects experienced as a result of taking this medication:
5. In the last six months, has your child had any muscular pain while exercising?
5.1. If yes, please explain and indicate where the pain has occurred:
5.2. Has a doctor or therapist treated this pain?
6. In the last six months, has your child experienced joint pain or pain in the bones?
6.1. If yes, please explain and indicate where the pain has occurred:
6.2. Has this joint pain, or pain in the bone been treated by a doctor or specialist?
7. Has your child broken any bones or suffered injury to their bones in the last 12 months?
7.1. If yes, please explain where and how the break/injury occurred:
8. Does your child have, or has your child had difficulty/problems with any of the following:
9. Has your child ever experiences a brain or spinal injury?
10. Does your child use a 'puffer' or 'ventilator' for asthma?
11. Does your child self-administer insulin for diabetes?
12. Does your child have any chronic disability or chronic illness?
12.1. If yes, please indicate the condition:
e.g. Cerebral Palsy, ADHD, Downs Syndrome, Obesity, Intellectual Impairment.
13. Is your child allergic to food, medications, pollens or other alleges or specific environments?
13.1. If yes, please explain what causes have been identified with this/these allergy/allergies:
14. Does your child have a prescription for an Epipen?
*
15. Does your child follow a special diet?
*
16. Has your child ever been diagnosed with a nutritional deficiency (such as non-iron deficiency)?
16.1. If yes, please specify the nutritional deficiency:
17. Has your child had surgery in the previous 12 months?
17.1. If yes, please specify:
18. Are you aware of any medical reason/condition which might prevent your child from participating in an exercise program?
18.1. If yes, please explain:
19. What are your child's favourite hobbies or interests?
20. Does your child aspire to compete any upcoming events? Please state:
Informed Consent
I hereby acknowledge that:
• The information provided above regarding my child's heath is, to the best of my knowledge, correct.
• I will inform you immediately if there are any changed to the information provided above whilst my child is participating in a Fired Up Fitness Youth / Teensfit Training Program.
• I give permission for my child to commence your physical activity training program.
• I understand my child participated entirely at his/her own risk, and must exercise due care to ensure his/her personal health and safety, and that of others.
• I have explained to my child that they need to listen and follow any directions or advice affecting their safety and that of others, given to them by a Fired Up Fitness Youth / Teensfit Team Trainer.
Parent/Guardian - Print Name to sign
Date Signed (DD-MM-YYYY)
