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Gym Access Permission Request Form
First Name
Last Name
Cambridge University Email address
Has your doctor ever informed you that you have a heart (or other) condition that means that you should either not do certain types of exercise or only under supervision?
Yes
No
Do you feel pain in your chest when you do physical activity?
Yes
No
In the past month have you had pain in your chest when NOT doing physical activity?
Yes
No
Do you lose balance due to dizziness or do you ever lose consciousness?
Yes
No
Do you have any bone or joint problem that could be made worse by different/increased physical activity?
Yes
No
Are you currently taking prescribed medication for a heart condition or your blood pressure?
Yes
No
Are you aware of any other reasons why you should not take part in physical activity?
Yes
No
If you answered ‘Yes’ to any of the above questions you should consult your doctor to confirm that they are happy for you to undertake the proposed programme of exercise. Even if you answered ‘No’ to all of the above, you should continue to monitor your own health for signs of significant illness/injury and contact your doctor if you are in any doubt.
I have responded Yes to one or more of the questions above and have discussed this with my doctor who has confirmed that they are happy for me to proceed with the proposed programme of exercise.
I have read, understood and accurately completed the above questionnaire and will inform the College if I am aware of any reason why I should not continue to use the equipment, or may need to take the advice of a suitably qualified personal trainer.
I have read, understood and agree to the
Pembroke Gym Rules
.
I have looked at the
instructions for the equipment
I intend to use and am confident I understand how to use them safely.
I understand that submission of this form does not grant me immediate access to the room and that permission will be added to my card usually within 2 working days.
I will only use the access on my card to grant myself entry to the gym.
Leave this field blank
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