Name *

First Name

Last Name

DOB *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor? *

YES

NO

Do you feel pain in your chest when you do physical activity?Checkbox 1 *

YES

NO

In the past month, have you had a chest pain when you were not doing physical activity? *

YES

NO

Do you lose balance because of dizziness or do you ever lose consciousness? *

YES

NO

Do you have a bone or joint problem ( for example back, knee or hip) that could be made worse by a change in your physical activity? *

YES

NO

Is your doctor currently prescribing medication for your blood pressure or heart condition? *

YES

NO

Do you know of any other reason why you should not take part in physical activity? *

YES

NO

Declaration of Liability *

I acknowledge that my engagement in the wellness retreat organised by Hester’s Outdoor Fitness & Lifestyle encompasses various physical activities, such as outdoor fitness, walking, and Pilates. I am aware that these activities carry inherent risks, and I willingly choose to participate with full understanding of these potential risks. In consideration of being permitted to partake in the wellness retreat, I hereby agree to release, indemnify, and hold harmless Hester’s Outdoor Fitness & Lifestyle, its representatives, instructors, and any associated partners from any and all liability, claims, demands, actions, or causes of action whatsoever arising out of or related to any loss, damage, or injury that may occur during the retreat, including personal injury, property damage, or loss of belongings. I acknowledge that Hester’s Outdoor Fitness & Lifestyle is not accountable for any personal belongings or valuables that I bring to the retreat. I understand that I will have the option to secure my possessions in the provided cottages during the activities, and I am solely responsible for ensuring the safety of my belongings. Furthermore, I affirm that I am in good health and physical condition to participate in the scheduled activities. In the event of a medical emergency, I authorise Hester’s Outdoor Fitness & Lifestyle and its representatives to seek medical assistance on my behalf. I have thoroughly read and comprehended the terms of this declaration. By endorsing this declaration, you confirm your understanding of the associated risks and your voluntary involvement in the wellness retreat activities. Should you have any inquiries or concerns, feel free to reach out. We eagerly look forward to sharing a rejuvenating and wellness retreat weekend with you! Sincerely, Hester Gaylard - Event Organiser

Emergency Contact *

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