Active Support Intake Form

To begin training with KAfit there are a few things we need to know. Please fill out the following intake form and attach all documentation requested.

First Name

Email Address

Last Name

Date of Birth

Phone Number

Address

Emergency Contact First Name

Emergency Contact Phone Number

Emergency Contact Last Name

Emergency Contact Relationship to Participant

Doctors Name

Medical Practice Phone Number

Medical Practice Name

Known Allergies

I consent to receiving First Aid and CPR by a certified person if required.

I consent to medical devices being used on my behalf if I am unable to do so for myself. For example; Epipen, Asthma puffer, etc.

NDIS Number

Line Item To Be Charged:

Will a support person be attending to support the participant?

Support Persons Full Name

Support Persons Phone Number

Plan Manager/Coordinators Full Name

Plan Manager/Coordinators Email Address

Plan Manager/Coordinators Contact Phone Number

Plan Manager/Coordinators Company

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TERMS & CONDITIONS OF THE UPLIFT PROGRAM

1. Full fees are charged if less than 48-hour notice is given of session cancellation.

2. You are to arrive AT LEAST 10 minutes before your session commencement time to settle into the space and toilet prior if needed.

3. You will bring your own towel and water bottle to all sessions.

Appropriate footwear based on the movement for the term must also be worn.

Additional aids like goggles for swimming must be supplied by the participant.

4. During all sessions you are responsible for your own personal belongings. Do not bring or leave valuables unattended.

4. You are required to provide your coach with notice via phone/text or email, including your full name if you are unable to attend your session.

Email: admin@kimberleyannefit.net

Phone: 0423 669 626

5. By booking and attending your session, you do so with full medical clearance. If you are unsure that you can participate safely you will obtain a medical certificate and present this to your trainer before commencing your first session. If you become injured and/or unwell during the term you are responsible for notifying your coach and you will not re-commence until you have let them know you are well enough to participate again. This is for the health and safety of yourself, the coach and other participants.

6. By booking and attending your session, you release your coach of Kimberley Anne Fit from any and all liability, damages, causes of action, allegations, suits, sums of money, claims and demands whatsoever, in law or equity, which the Client ever had, now has or will have in the future against Kimberley Anne Fit, arising from the Client’s past or future participation in, or otherwise with respect to, the Program, unless arising from the gross negligence of your Coach.

7. You consent to all photos being used for marketing and social media purposes by Kimberley Anne Fit. Names can be withheld by request.

8. Two weeks' notice is required for termination of service by either the participant or your coach.

I have read and agree to the terms of training and program conditions.

I declare that the medical information I’ve provided is accurate & complete.

I want to subscribe to the newsletter.

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Privacy Policy

Any Personal or Sensitive Information that we collect about individuals will be used and disclosed by us to provide the services required accurately and to their fullest.

Kimberley Anne Fit will only disclose Personal Information to third party business partners if they provide services to Kimberley Anne Fit that are consistent with the terms of the Privacy Policy. When we outsource or contract out specific support services, our contractors may access individuals’ Personal Information to ensure the correctness of their service. It is important to note that all our contractors are subject to strict confidentiality obligations.

Kimberley Anne Fit will disclose personal information if it is under a legal requirement to do so (for example, under a court order, or if required under legislation), or if an authorised request is made from a law enforcement agency.

Otherwise, we will only disclose Personal Information with the consent of the relevant individuals. If consent is obtained, we may provide Personal Information to relevant contractors or specific support services to assist customers to improve their fitness and well being.

Lifeline: 13 11 14