Membership Form




    Physical Activity Readiness Questionnaire

    Please complete this questionnaire before attending Kiveton Park Health & Fitness Suite

    Please read carefully:

    If you select any of the ‘yes’ options below you must have a Doctor’s consent before commencing in any activity.

    Has your doctor ever said that you have a heart condition and recommended only medically supervised activity?

    Do you have chest pain brought on by physical activity?

    Have you developed chest pain in the last month?

    Do you tend to lose consciousness or fall over as a result of dizziness?

    Do you have a bone or joint problem that could be aggravated by any proposed activity?

    Has the Doctor ever recommended medication for your blood pressure or a heart condition?

    Are you aware, through your own experience or from a Doctor’s advice, of any other physical reason why you should not exercise without medical supervision?

    Are you currently, or have been pregnant in the last six months?


    Kiveton Park Health & Fitness Suite Ltd (KPHFS) accept no liability for accidents, injuries or illness however caused whilst using the gymnasium. All patrons use the gymnasium at their own risk.


    Data Protection

    On joining the gym we require details from you for membership reasons.

    These may include some or all of the following on paper, electronic format or on membership software:
    – Health questionnaire
    – Email address
    – Telephone numbers

    All paper copies of your details are held securely on site and can only be accessed by KPHFS members of staff.

    Your information will not be shared with any third party companies, that it will be stored securely and will only be used within Kiveton Park Health & Fitness Suite Ltd.