Liability Waiver


Please complete this form as accurately as possible. If you have any questions please ask a Cycology Club team member for assistance. If you are under the age of sixteen (16) years, a parent or guardian must complete and sign this form on your behalf.

Full Name:

Date or Month of Birth:



Please read carefully and indicate your answers by circling YES or NO

1. Do you currently have any of the following:

Contagious disease YES / NO

Ailments YES / NO

Physical injuries YES / NO

Diabetes YES / NO

Osteoporosis YES / NO

High Blood Pressure YES / NO

High Cholesterol YES / NO

2. Have you ever been diagnosed with any of the following:

A heart condition YES / NO

A stroke YES / NO

Asthma YES / NO

Hypoglycaemia YES / NO

Diabetes YES / NO

Arthritis YES / NO

Anorexia YES / NO

Bulimia YES / NO

Anaemia YES / NO

Epilepsy YES / NO

Respiratory Ailments YES / NO

Back problems YES / NO

3. Are you aware of any disability or impairment that would make attending a Cycology Club class hazardous or detrimental to your health, safety and/or wellbeing?  YES / NO

4. Do you ever have pains in your chest while performing physical activities of any kind? YES / NO

5. Have you ever had pains in your chest while not performing any physical activity? YES / NO

6. Have you ever lost your balance due to dizziness? YES / NO

7. Have you ever lost consciousness? YES / NO

8. Have you recently had surgery? YES / NO

9. Are you currently taking medication, either prescription or non – prescription? YES / NO

10. If you answered ‘yes’ to Question 9, are you aware whether this medication may affect your ability to exercise? YES / NO

11. If you answered ‘no’ to Question 10, have you checked with your medical practitioner? YES / NO

If you answered YES to any of the above questions, please elaborate below/over and seek guidance and a clearance in writing from your Physician or health professional prior to undertaking any physical activity or exercise.





Please note:

Riding while affected by stimulant recreational and prescription drugs poses a significant risk of heart attack, seizures and death. By signing this waiver you agree that you will not participate in classes at Cycology Club under the influence of these drugs. By signing this waiver, you agree to notify Cycology Club if your health condition changes at any time during the period of time that you participate in Cycology Club classes. If your health condition ever presents a limitation on your physical activity level, please notify your instructor and seek their prior advice on the

appropriate modifications to your session. By signing this waiver, you also agree that Cycology Club is not responsible for the loss or theft of any personal property in the studio or property surrounds including in lockers or with our concierge service. By signing this waiver, you agree that you meet the minimum height requirement of 150cm.

I, _______________________________________________ acknowledge and confirm that I fully understand and have fully answered truthfully and to the best of my knowledge all the above questions and agree to waive and release Cycology Club from all liability for any loss, injury or death.