PAQ Personal Information. First Name (required) Last Name (required) Address (required) Suburb (required) Postcode (required) Mobile Number (required) Home Phone Number Your Email (required) Date of Birth (required) Gender (required) MaleFemale In Case of Emergency Emergency Contact Name (required) Emergency Contact Number (required) Medical Information All medical information is kept confidential and only view by AQUACAMP77 staff Current Illness (eg: flu, fever)... YesNo Covid-19 area Have you been Double Vaccinated against Covid-19? YesNo Have you tested positive for COVID-19 in the last 4mths? YesNo Have you been in contact with anyone diagnosed with Covid-19? YesNo Date Have you had to self isolate due to Covid-19? YesNo Heart Condition (pain or tightness in chest)... YesNo Epilepsy, fits or blackouts... YesNo High Blood Pressure... YesNo Circulatory Problems... YesNo Asthma... YesNo Diabetes... YesNo Arthritis... YesNo Joint Damage... YesNo Back Problems... YesNo Are you pregnant? YesNo Have you had a baby in the past 6 weeks? YesNo Do you smoke? YesNo If you answered "Yes" to any of the above questions, please give details: Fitness Self Assessment How often do you exercise in a week? (required) NoneOnceTwiceThree TimesMore than 3 times What do you rate your fitness level? (required) 12345678910 Can you swim 20 meters? (required) No With the aid of a noodlekickboardSlowlyComfortably Do you fear any water activity (ie; face or head under water) (required) YesNo Where did you hear about AQUACAMP77?: (required) Disclosure of Medical Conditions I represent and warrant to AQUACAMP77 that I have disclosed details of any medical condition I have and of all recent medical treatment received by me. I have read the questions/information understand it and any questions which may have occurred to me have been answered to my satisfaction. (required)Agree Indemnity and Risk Waiver In the case of an emergency, I authorize the AQUACAMP77 staff, where it is impractical to communicate with me, to arrange for me to receive such medical or surgical treatment as may be deemed necessary. I also undertake to pay or reimburse costs which may be incurred for medical attention, ambulance transport and drugs whilst I am in a AQUACAMP77 program. For any child under the age of 16, Aquacamp77 takes no responsibility for in the pool and around the pool deck. (required)Agree