Step 1 of 4 - Next 25% Name* First Last Email Address* Sex*MaleFemale Date of Birth* *You must be 18 years or older to become a member and proceed forward.*Emergency Contact Name* First Last Emergency Contact Number* Have you ever suffered from the following?* None High Blood Pressure Pain / Tightness in Chest Any Heart / Stroke Condition Diabetes Epilepsy Do you have / have you experienced* None Breathing Difficultly or Asthma? Hernia Arthritis Back Pain - Have you been hospitalised in the last 6 weeks?*YesNoIf yes, Why?*- Are you aware of any other medical condition which could affect you during your time in the gym?*YesNoIf yes, please describe*Are you on medication in relation to exercise?*YesNoIf yes, please describe*How would you describe your current physical condition?* Fit Unfit Healthy Overweight Upload a photo of yourself*Accepted file types: jpg, gif, png.Image uploaded must be in .jpg, .png or .gif format only.* I confirm that I understand the questionnaire I have just completed above and that to the best of my knowledge the information is correct. * I confirm that I understand while Neyland CIC will make every reasonable attempt to ensure the gym is well maintained I exercise in Neyland Community Gym entirely at my own risk. * I understand that if my medical condition history changes after completing this form I am required to update this record as soon as possible by email to [email protected] Because you have experienced or suffered from one of the medical conditions listed we would strongly advise that you seek advise from your GP before using the Neyland Community Gym. If you have done so, please confirm below. * I confirm I have consulted my GP about my use of the Gym and confirm there is no reason why I should not use the Neyland Community Gym unsupervised. If you have not then unfortunately we are not able to let you register at this time. Induction Neyland CIC does not employ staff at Neyland Community Gym and there-fore has arranged for inductions to be provided by [To be Confirmed]. Please select the appropriate statement; *I have had an induction at a gym facility previously (e.g. A Pembrokeshire County Council Leisure Centre). I am aware that an induction is available should I require one.I have never had an induction and will require one before using the Neyland Community Gym. I will contact [email protected] directly to arrange one.Please note that if you have not already had an induction we will not be able release your Gym Access fob (and you will be unable to use the gym) until it has been confirmed that your induction has taken place. Senior SportIf you regularly play senior sport for one of the following clubs then please select them from the list below Neyland Rugby Club (Including Youth) Neyland Cricket Club Neyland Football Club Neyland Bowls Association It may be that your club has agreed a discount on your behalf but please note this is entirely at the discretion of the respective clubs. If they have done so and they confirm you as a regular playing member, your discount will be applied automatically. Please also note this discount will end automatically if your club informs us you are no longer a regular playing member.