First Time Class Data Protection - Form Full Name Phone Number Date of Birth Address (Only Town) Your Email 1. Data Protection Confirmation and Authorisation: I ( Please enter your name below ) hereby authorise Fit&Joy Ireland to hold all personal information provided by me and to use this information for any purpose necessary in providing services to me. 2. I Agree that Fit&Joy Ireland may use my personal data to send me promotional information, conduct surveys and otherwise communicate with me to update me in respect of the services provided by Fit&Joy Ireland, subject to data protection regulations provided by law. I understand 3.I Agree that Fit&Joy Ireland has my express and implied permission to display images or videos in groups to all online social media platforms such as Facebook, Instagram etc. I understand 4. I understand that Fit&Joy Ireland will not provide my personal data to any third parties (other than as set out above) and will maintain my personal data securely either electronically or in paper format or both. I that I have the right to have this data returned to me upon request and removed from Fit&Joy’s Ireland records unless Fit&Joy Ireland requires same for legitimate business reasons, other than promotional reasons. In all circumstances I maintain my right to be forgotten, as provided by law. I understand Medical details Please reply to the following: 1. Do you have any medical condition or have you received medical advice that Yes No which requires you to restrict your physical activity. Yes No 2. Do you have any medical condition which we need to be aware of e.g. High blood pressure, heart condition, muscular conditions, back injury, Asthma etc. Yes No 2-1 If yes please give details 3. Do you suffer from chest, back or other pain when physically active Yes No 4. Do you ever lose balance, consciousness, become dizzy Yes No 5. Do you have any bone or joint problem that could be aggravated by physical activity or any other such condition which we need to be aware of Yes No 6. Are you on any medication Yes No 6-1. If yes please give details of condition and medication been taken 7. Is there any other information in your medical history or in relation to your physical health and wellbeing that we need to be aware of or that you feel might be relevant Yes No 7-1. If yes please give details 8. Are you pregnant? Yes No Please note that you should update the instructor with any relevant information before each class. If you do not update the instructor before each class it will be assumed that you information has not changed. Understood Note management retain the right to request a certificate of medical fitness before commencing classes. Understood DISCLAIMER: I am aware that the classes I undertake with Fit&Joy Ireland require physical activity that may be more rigorous than that which I am currently accustomed to. I hereby acknowledge and understand, on behalf of myself , that my participation in Zumba Classes/ Step Aerobic/ Toning could result in our exposure to bodily injury, illness (including, but not limited to viruses such as COVID-19), loss or death, as well as property losses and/or damage to property. For and in consideration of the licensed Zumba® / Step Aerobic/ Fitness instructor (the “Instructor”) permitting me to enroll and participate in the Classes, and in recognition of the possible dangers to which I voluntarily by participating in the Classes and related activities. Confirmed CONFIRMATION I have read and fully understand the details contained in this form and have been give the opportunity to ask any questions and to provide any information which I feel relevant to the instructor. Confirmed IN THE CASE OF A MINOR I ( enter name below ) parent/guardian hereby confirm that the information contained in the form above in respect of ( enter name below ) is true and accurate and I have read and understood the above disclaimer and I hereby indemnify Fit&Joy Ireland in respect of all claims, proceedings, liability, costs howsoever and in whatever manner arising. I further confirm that I have read and understood the Data Protection Confirmation above and hereby confirm my consent and authorisation in respect of same. Today Date: Send
