Vector Health

OPEN DAY - STRAPPING CLINIC SELECTIONS

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Athlete/Client 1

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Athlete/Client Details

Athlete/Client First Name

Athlete/Client Last Name

Date of Birth

Gender

Male Female

Email Address

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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?

Sport (if applicable)

How did you hear about us?

Dates

From 18-May-2019 to 18-May-2019

Days & Times

Once a time slot is full you will be asked to make another choice.

	Saturday, 18-May-2019	09:50 AM	to 10:20 AM	102 William Street (Vector Health)	WRIST
	Saturday, 18-May-2019	11:30 AM	to 12:00 PM	102 William Street (Vector Health)	ANKLE

DISCLAIMER:
I hereby agree to assume all risks and responsibilities surrounding my (or my child's) participation in the program under the instruction of Vector Health 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 Vector Health, 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

I agree

Signed

Date

19-Apr-2024

Media Consent

1) I, the undersigned, hereby authorize Vector Health to photograph me, take motion pictures of me, take video footage of me, and/or make electronic sound recordings of me (herein referred to as photographic or electronic reproductions).

YES

2) I authorize the use of any such photographic or electronic reproductions of me for any purpose, including, but not limited to educational and other public media as may be deemed appropriate by Vector Health (I understand that I may be identifiable from such photographic or electronic reproduction)

YES

3) PARENTAL CONSENT - This applies if you are enrolling a child under the age of 18 years in your care. I certify that I am the parent or guardian of the individual above who is a minor under the age of eighteen years. I hereby agree to assume legal responsibility for his/her authorizations referred to in this General Media Release.

YES

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