One to One Training Registration

Preferred Centre LoughlinstownMeadowbrookMonkstown

Your Details

First Name *

Surname *

Gender Male Female *

Date of Birth *

Email Address *

Address 1 *

Address 2 *

Address 3

County Dublin Wicklow Meath Kildare *

Telephone

Mobile 083 085 086 087 089 *

Alternative Mobile 083 085 086 087 089

Profile:

Occupation *

What's your reason for 1:1 training? Select Increase Fitness Level Weight Loss/Tone up Rehabilitation of injury Change in Programme Nutrition Assistance in the Gym Teen 1:1 Training *

How much exercise do you do? Select Not at all Once a week Twice a week Three times a week Four times a week More than four times a week *

Are you on any medication? Please select No Yes *

Do you have any injuries? Please select No Yes *

Do you have any alergies? Please select No Yes *

Are you affected by any of the following? Please tick where applicable.

Do you have any special needs? Please select No Yes *

Do you smoke? Please select No Yes *

Do you drink? Please select No Yes *

How did you hear of our 1:1 training? Please select Internal posters Staff Radio Newspaper Flyer drop Brochure Newspaper Website Email School Other *

I wish to receive further information on special offers and updates at my local centre by post/email/SMS.

By selecting this check box and the Submit button, I understand and answered the above questions fully and to the best of my knowledge. I understand the risks and dangers inherent in physical exercise and I agree to release, discharge and absolve the agents, employees and instructors from any liability arising from any accident, injury or loss sustained by me as a result of activities at present offered in this centre. I also agree to these Terms and Conditions