Croí Exercise Form Home / Croí Exercise Form Name(Required) First Last Gender(Required)FemaleMaleAge(Required)Phone(Required)Email(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Emergency Contact/Next of Kin Name(Required) Emergency Contact/Next of Kin Phone Number(Required) GP Name(Required) Has your Doctor ever said to you that you should only do physical activity or exercise as recommended by a Doctor?(Required)YesNoPlease provide details if releventDo you ever feel pain in your chest, jaw or left arm when doing physical activity or exercise?(Required)YesNoPlease provide details if releventDo you ever feel pain in your chest, jaw or left arm at rest?(Required)YesNoPlease provide details if releventDo you ever lose your balance due to dizziness or do you ever lose consciousness?(Required)YesNoPlease provide details if releventDo you have a bone or joint problem that could be made worse by a change in your physical activity?(Required)YesNoPlease provide details if releventHave you ever experienced any pain whilst exercising which caused you to stop?(Required)YesNoPlease provide details if releventHave you ever suffered any musculoskeletal injury, e.g. ligament strain, tendon or muscle injury or fractures (broken bones)?(Required)YesNoPlease provide details if releventAny other relevant information that the instructor should be made aware of, e.g pregnancy or any recent diagnosis that may impact on your exercise participation?(Required)YesNoPlease provide details if releventOther Medical Conditions(Required)StrokeEpilepsyClaudicationCOPD/AsthmaNeuro ProblemsRecent Cardiac EventOtherNoneIf other, please specifyConsent(Required) I confirm that I have read and understood the terms stated below. If there are any future changes to your medical health or prescribed medications, please notify the class instructor.Disclaimer: For In-Person Classes: Participating in this exercise class is done at your own risk. Croí cannot be held responsible or liable for any injury or harm incurred while exercising during the class. Please keep properly hydrated throughout the exercise session. If you feel unwell at the beginning of each class or at any stage during the class, please inform the class instructor. For Virtual Classes: participating in this virtual exercise class is done at your own risk. Croí cannot be held responsible or liable for any injury or harm incurred while exercising at home during a virtual exercise class. Please take all necessary precautions to ensure your exercise environment is free of clutter, well-lit and ventilated. Please also keep properly hydrated throughout the exercise session. If you feel unwell at the beginning of each class or at any stage during the class, please inform the class instructor. Monday Movers Walking Group: Participating in this walking group is done at your own risk. Croí or the volunteer walking leaders cannot be held responsible or liable for any injury or harm incurred during the walk(s). Please keep properly hydrated and wear appropriate footwear and clothing. If you feel unwell at the beginning or at any stage during the walk, please inform the walking leaders. Walking Football: Participating in Walking Football is done at your own risk. Croí cannot be held responsible or liable for any injury or harm incurred during Walking Football. Please keep properly hydrated and wear appropriate footwear and clothing. If you feel unwell at the beginning or at any stage during a game, please inform the instructor.