Vision Exercise Physiology

Client 1

Client Details

Client First Name

Client Last Name

Date of Birth

Gender

Email Address

Confirm Email Address

Create your password

Enter the password that you would like to use for your new account.

Confirm your password

Home Phone

Mobile/Cell

Parent/Guardian Details

Mother's Name

Mother's Email Address

Mother's Mobile/Cell

Father's Name

Father's Email Address

Father's Mobile/Cell

Address

Address 1

Address 2

Suburb/Town

State/Prov

Zip/Postcode

Health and Fitness

Do you have any injury concerns?

Do you have any medical conditions?

How did you hear about us?

Training Dates

DISCLAIMER:
I hereby agree to assume all risks and responsibilities surrounding my (or my child's) participation in the program under the instruction of Vision Exercise Physiology coaches. I understand that similar to all sporting activities, there is a risk of damage to personal property, injury or death which may result from causes beyond the control of, and without fault or negligence of Vision Exercise Physiology, its officers, agents, or employees, during the period of my (or my child's) participation. I understand completely the above agreement and agree to be bound thereby. By registering on our site you agree that we may send you email related to our facilities and programs. We will not provide your details to any other company.

Agreement

Please mail this form with a payment attached to: "Vision Exercise Physiology, 324 Hume Street, Toowoomba QLD 4350"