COMPLETE YOUR ENROLMENT Course enrolment form COURSE: Level 3 Diploma in Gym Instructing and Personal Training Ensure all fields are completed fully and correctly as we will use these details for your certification Title (Mr, Mrs, Miss, Ms) Full name (as it should appear on your certificate) Date of birth (dd/mm/yyyy) Full address (Ensure correct as this is where we will post your certificate to) Email* Phone How did you hear about PTA? Google/ Web search Instagram Facebook Gym advertisement Word of mouth Ethnicity White Mixed - White and Black Carribbean Mixed - White and Black African Mixed - White and Asian Mixed - Any other background Asian or Asian British - Indian Asian or Asian British - Pakistani Asian or Asian British - Bangladeshi Asian or Asian British - Chinese Asian or Asian British - Any other Asian background Black or Black British - African Black or Black British - Caribbean Black or Black British - Any other Black background Other ethnic group - Arab Prefer not to say Other ethnic group Learning diffilculties No learning difficulties Moderate learning difficulties Severe learning difficulty Dyslexia Other specific learning difficulty Autism, spectrum disorders Multiple learning difficulties Other Disability No disability Visual impairment Hearing impairment Disability affecting mobility Other physical disability Other medical condition Emotional/Behavioural difficulties Mental health difficulties Temporary disability after illness Profound complex disabilities Aspergers syndrome Multiple disabilities Other Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? Yes No Do you feel pain in your chest when you perform physical activity? Yes No In the last month, have you had chest pain when you were not performing any physical activity? Yes No Do you lose your balance because of dizziness or do you ever lose consciousness? Yes No Do you have a bone or joint problem that could be made worse by a change in your physical activity? Yes No Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? Yes No Do you know of ANY other reason why you should not engage in physical activity? Yes No Any further information you would like us to know prior to commencing our practical workshops? Submit
