Expressions of Interest

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Free

First Name:* First Name Required

Last Name:* Last Name Required

Address Line 1:* Address Line 1 is Required

Address Line 2: Address Line 2 is not valid

City:* City is Required

Country:* Country is Required

State/Province:* State/Province is Required

Zip/Postal Code:* Zip/Postal Code is Required

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Mobile Phone Number:* Mobile Phone Number is Required

Gender:* Gender is Required

Male Female Prefer not to say

Age in years:* Age in years is Required

Company Name (Enter NA for Individual):* Company Name (Enter NA for Individual) is Required

Where did you hear about us?:* Where did you hear about us? is Required

PRE-EXERCISE HEALTH SCREENING - please see notes at bottom of page*
Time Out Tai Chi is designed to be a light to light-moderate form of exercise. If you have been inactive, we recommend pacing yourself and slowly increasing your volume and intensity.

I have been cleared to participate in this Time Out Tai Chi course as my doctor has cleared me to exercise or I am able to answer NO to the following:* PRE-EXERCISE HEALTH SCREENING - please see notes at bottom of page*
Time Out Tai Chi is designed to be a light to light-moderate form of exercise. If you have been inactive, we recommend pacing yourself and slowly increasing your volume and intensity.

I have been cleared to participate in this Time Out Tai Chi course as my doctor has cleared me to exercise or I am able to answer NO to the following is Required

Has your medical practitioner ever told you that you have a heart condition, or have you ever suffered a stroke? 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 an asthma attack requiring immediate medical attention at anytime 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?

Choose the appropriate response:* Choose the appropriate response is Required

READY TO GO - I have ticked all of the Pre-exercise Health Screening questions CLEARED TO ATTEND – I have ticked one or more of the questions and have consulted my GP or appropriate allied health professional before undertaking physical activity/exercise. NOT CLEARED TO ATTEND – I have not been able to tick one or more of the questions and understand I will not be able to attend class until I have received guidance from my GP or appropriate allied health professional.

I warrant that the details that are contained in this application are true and correct*

I have read the Direct Debit Request and agree with the terms and conditions governing the debit arrangements between myself and Stripe*

I have read and agree that we may handle your personal information in accordance with the Balance Minder Privacy Policy*

Exclusion Notice:* Exclusion Notice is Required

Are you a registered exercise professional? Please list where your registration is held and membership number.:* Are you a registered exercise professional? Please list where your registration is held and membership number. is Required

Pre-requisite minimum Cert III in Fitness for Fitness Australia accreditation held in order to obtain CECs. Do you hold a Cert III in Fitness or higher?:* Pre-requisite minimum Cert III in Fitness for Fitness Australia accreditation held in order to obtain CECs. Do you hold a Cert III in Fitness or higher? is Required

Yes No

Do you hold a nationally recognised training qualification in Exercise for Children? :* Do you hold a nationally recognised training qualification in Exercise for Children? is Required

Yes No

If yes, please list details and upload copy below: If yes, please list details and upload copy below is not valid

Do you hold a nationally recognised training qualification in Exercise for Older Adult? :* Do you hold a nationally recognised training qualification in Exercise for Older Adult? is Required

Yes No

If yes, please list details and upload copy below: If yes, please list details and upload copy below is not valid

Please advise if you require any other assistance, to aid your learning experience: Please advise if you require any other assistance, to aid your learning experience is not valid

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We handle your personal information in accordance with the Balance Minder Terms of Service and Privacy Policy. I have read and agree this document.*

No val Please fix the errors above

About the Health Screening

IF YOU HAVE ANSWERED ‘YES’ to any of the 7 questions, we cannot accept your registration. Please seek guidance from your GP or appropriate allied health professional prior to undertaking physical activity/exercise.

IF YOU HAVE ANSWERED ‘NO’ to all of the 7 questions, and you have no other concerns about your health, you may proceed to undertake light-moderate intensity physical activity/exercise.

About the Health Screening

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