Breadcrumb Home Canada Bay Active Canada Bay Active Complete the form below to be part of the free the Canada Bay Active program. Join Canada Bay Active Indicates required field First name Surname Gender Male Female Date of birth (DD/MM/YY) Address Suburb Postcode State - Select -NSWQLDVICTASACTNTSAWA Company name/employer Occupation Which location will you attend Rhodes Mill Park Chiswick Wire Mill Park (adjacent to Chiswick Community Centre) How will we contact you? Email Contact number Emergency contact name Emergency contact number As part of our duty of care, it is a requirement to ask all participants, no matter what age, to complete the following questions. Has a family member (under 60), suffered from heart disease, stroke, raised cholesterol or sudden death? Yes No Are you a male over 35, or a female over 45 and not used to regular exercise? Yes No Have you been hospitalised recently? Yes No Are you pregnant? Yes No Have you given birth in the last 6 weeks? Yes No Are you on any prescribed medication? Yes No Do you have any heart conditions? Yes No Do you have high blood pressure (>149/90)? Yes No Do you have, or have you ever had? Gout Stroke Diabetes Epilepsy Hernia Arthritis Glandular fever Rheumatic fever Dizziness or fainting A liver or kidney condition Stomach or duodenal ulcer Heart murmur Palpitations or pain in the chest High cholesterol Asthma Muscular pain Other None of the above Other (please specify) Do you have any pain or major injuries in the following areas? Neck Knees Back Shoulders Ankles None of the above Tell us about yourself, and your activities: The measurements you give us need to be accurate. Please measure yourself to obtain this information. This will help form the basis of your personal information and will effect the advice and assistance we give you. Height (cm) Weight (kg) How many times a week do you exercise? - Select -4+ times a week2-3 times a week1 time per weekNot in the past 1-3 monthsNot in the past 6 months How active are you during your daily life? - Select -Not active at allLightly activeModerately activeHeavily active Do you follow a special diet? If you have any dietary issues or concerns, please consult your doctor before following any new nutrition plan Do you smoke? - Select -NoYes - 1 per dayYes - 2 to 3 per dayYes - 4 to 5 per dayYes - 5+ per day Personal health and fitness goals I'm looking to achieve: Losing some weight and toning up Improve overall health and fitness Improve overall strength Socialise with others and relaxation Participants self clearance * Acknowledgement: The City of Canada Bay outdoor group fitness sessions are designed for all levels, and we welcome all shapes, sizes and ages (18+) in the community. If you have ticked any of the above, are in poor health, or have a pre-existing medical condition, we strongly recommend you consult your general practitioner before beginning a new fitness program. You acknowledge that, by participating in these sessions, you are doing so voluntarily and, depending on your particular circumstances, there may be risks to your health. You are responsible to make your own enquiries and seek independent advice from a healthcare professional before acting on any information or material made available. Please tick I warrant that I am physically and mentally well enough to proceed with the City of Canada Bay's 'Free Outdoor Fitness Sessions' I accept this 'Participants Self Clearance' for any previously acknowledged medical conditions during this registration The City of Canada Bay FREE outdoor fitness program is designed for adults aged 18+ years. I confirm I am 18+ years or older I accept the City of Canada Bay is providing the opportunity to participate in group training classes, and that I should consult my GP before taking part/or booking in to any sessions I would like to receive news updates from Concord Oval Recreation Centre Sign up for our newsletter Stay up to date with the latest news from the City of Canada Bay's recreation centres. First name Email