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= Required Fields

Online Form - SALT Senior Adults Living Triumphantly Registration Form

General Information


Emergency Contact information (must live in Hedland)


Health Information

If you answer 'YES' to any of the health information questions, you will need to receive medical clearance from your doctor prior to participating in the program.

Are you currently taking prescribed medication(s) for any condition(s)? If yes, please list.
Has your Medical Practitioner ever told you that you have a heart condition or have suffered a stroke?
Do you have any diagnosed muscle, bone, tendon, ligament or joint problems that you have been told could be made worse by participating in exercise?
Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?
Do you ever feel faint dizzy or lose balance during physical activity/exercise?
Have you had any respiratory requiring immediate medical attention at any time over the last 12 months?
If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months?
Do you have any other conditions that may require special consideration for you to exercise?

Do you require free bus transport from your residence to and from the sessions? *

Declaration

I declare and acknowledge that:

I have made the Town aware of any physical, mental or health conditions that may be aggravated, worsened or be impaired by physical activity participation in this program. I agree that I meet the medical standards to take part in the SALT program and will inform the instructor of any conditions that may arise throughout my participation in the program.

If required, the Town will arrange for medical or hospital treatment (including ambulance transport) for me. I authorise such action being taken by the Town and agree to meet all costs associated with such action.

Participation in the SALT program involves risk of injury and loss or damage to property and that I participate in the SALT program at my own risk.

The Town, its staff, volunteers or agents, are not liable for any personal injury, loss or damage of property or expenses, including medical expenses, which I may suffer from participation in the SALT program.

Please note - If any attendee/s require a support person/carer to be present in order to participate in this program, then that support person/carer will need to be in attendance for the duration of each 1.5 hour.

Do you accept this declaration? *