Sign In Form / Disclaimer by marcedwards | Apr 18, 2014 | Uncategorized Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone*Email* Date of Birth* Next of Kin Name*Next of Kin Contact Number*Doctor Name*Doctor Surgery / Contact*Do you suffer / Have you suffered from any of the following? Rheumatoid or Osteo Arthritis Head / Neck Injury Shoulder/Arm/Wrist/Hand Injury Back Pain / Injury Hip / Pelvis Injury Do you suffer / Have you suffered from any of the following? Knee / Thigh / Leg Injury Ankle / Foot Injury Nerve Damage Swollen Joints Fractured Bones Do you suffer / Have you suffered from any of the following? Heart Problems Diabetes Epilepsy Early menopause Cancer If You answered yes above, please provide detailsAre you currently recieving treatment for anything?YesNoHave you had major surgery in the last 10 years?YesNoHave you had minor surgery in the last 2 years?YesNoIf you answered yes to the above, please provide detailsDo you suffer / have you suffered OR have you ever had a medical consultation for any of the following conditions?AsthmaEpilepsyHigh / Low Blood PressureHeart Conditions / ProblemsChest PainsIf You answered yes above, please provide detailsAny other health issues not already mentioned, please list here:Are you pregnant?YesNoHave you ever been diagnosed with a learning disability / have any problems learning in school / require any special provision for assessments because of learning issues?*YesNoI understand that certain elements of the Session/Course can be physically demanding. I accept full & complete responsibility for my participation in the practical elements of this session/course*YesI agree that Universal Training, Marc Edwards Fitness & Representatives' are free of any/all liability of injury or health problem that may result from/be aggravated by my participation*YesI agree that Universal Training, Marc Edwards Fitness & Representatives' are free of any/all liability for death, injury or health problem that may result from/be aggravated by this training with 3rd parties*YesI understand that by signing this / completing this form that any use of excersises post course/workshop/session, I assume all responsibility for demonstrations and the safety of the end user*YesIs this submission for a *Course *Workshop *Seminar *Fitness Class *Personal Training? If so, Which is it and please select the course/class name. For example: Fitness Class - Kickboxing*Universal-Training SeminarUniversal Martial Arts Training SeminarUniversal Fitness Industry Training SeminarPink Belt Kickboxing Official ProgrammePink Belt Kickboxing GrX ProgrammePink Belt Kickboxing ICPPink Belt Kickboxing GrX ICPWAKO ICC L1WAKO ICC L2Personal Training Session(s)Fitness ClassKickboxing Class (K500)Online Personal Training CertificationOnline Personal Training Certification MentorshipOtherIf you selected Other above, Please give detail here:If you have chosen the Personal Training Certification Mentorship Package, Please select the preferred CPDs from the list below:CPD - Functional TrainingCPD - Kettlebell Instructor TrainingCPD - Circuit TrainingCPD - Nutritional StrategiesCPD - Advanced PadWorkUniversal Training, Marc Edwards Fitness and Representatives means anybody delivering a training session / Course / Workshop in association with / on behalf of Marc Edwards or Associated Training Provider (REPs Accredited or not) and any Training Session/Course/Class/Workshops including (but not limited to) any of the following names: Marc Edwards Fitness / K5 Health and Fitness / Universal Training / Universal Fitness Training / Universal Martial Arts Training / Universal Personal Training / K500 Kickboxing / Jordan Fitness / WAKO GB / Quantum HFE / Leisure Lines Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window)Click to share on Google+ (Opens in new window) Related