Pre-exercise health form

Pre-exercise health form

Youth and community programs
Your details
Name*

Given nameFamily name
Email*
Contact number*
Emergency contact number*
Date of birth*

DayMonthYear
Date
How do you describe your gender?*

WomanManNon-binaryI don't knowI prefer not to answerI use a different term (please specify)
Program selected*

Youth hip hop danceYouth Maybanke basketballCommunity mums and bubs fitnessYouth Peter Forsyth Auditorium basketball workshopsYouth tennis lessonsCommunity walking soccer at UltimoCommunity walk and talkYouth boxingYouth school holiday programYouth end of year pool partyYouth rowingYouth freestyle footballOther
Are you able to swim 100 meters?*

YesNo
Other interests*

CookingCommunity eventsCommunity walksMusic and artVolunteeringNone
Please indicate any pre-existing medical conditions

AllergiesAsthmaBroken bonesChest painsDiabetesEpilepsyFaintingHeart attackHeart diseaseHeart murmurHigh blood pressureLow blood pressureOedemaPalpitationsPneumoniaRecent childbirthRecent surgerySeizuresShortness of breathStrokeTachycardia
Swimming ability
Can you swim 25m unassisted?*

YesNoNot applicable
If any of these conditions are indicated, please provide written medical clearance from your GP.
Agreement*

I have read and understood the exercise advice and privacy and personal information protection noticeI have completed the pre-exercise health form accurately and truthfullyIf any pre-existing medical conditions have been indicated I will obtain advice from a GP or appropriate allied health professional before commencing exerciseI agree to abide by all terms and conditions of access to City Spaces at all times as directed by City of Sydney Staff.
Date*

DayMonthYear
Date
Privacy protection notice
Purpose of collection: This information is being collected for the purpose of providing a community program and service

Intended recipients: City of Sydney employees are the intended recipients.

Supply: The supply of this information voluntary. If you are unwilling to provide this information, the City of Sydney may be unable to provide access to City of Sydney services.

Access/Correction: Please contact customer service on 02 9265 9333 or at council@cityofsydney.nsw.gov.au to access or correct your personal information.

Storage: The Social Programs & Services unit at the City of Sydney, located at 456 Kent Street, Sydney NSW 2000, is collecting this information and the City of Sydney will store it securely.

Other uses: The City of Sydney will use your personal information for the purpose for which it was collected and may use it as is necessary for the exercise of other functions.

For further details on how the City of Sydney manages personal information, please refer to our privacy management plan.
Should be Empty:

Pre-exercise health form

Your details

Swimming ability

Privacy protection notice