---

Section 1 - Patient Details

First Name*:	This field is required.
Last Name*:	This field is required.
Gender*:	Male Female Self-describe  Prefer not to say
Date of Birth*:	This field is required.
Ethnicity*:	Select Ethnicity Afghani African American Bangladeshi Canadian Chinese Cook Island Cook Island Māori Fijian Filipino Indian Japanese Kiribati Korean Latin American / Hispanic Māori Middle Eastern N/A Nepalese New Zealand Māori Niuean NZ European Other Asian Other Ethnicities Other European Other Pacific Pakistani Samoan South African Southeast Asian Sri Lankan Taiwan Tibetan Tokelauan Tongan Tuvaluan This field is required.
NHI: (if known)
Street Address*:	This field is required.
Suburb*:	This field is required.
City*:	This field is required.
Postcode:
Email:	Invalid Email address.
Home Phone:
Mobile:
Work:

---

Section 2 - Medical Conditions

---

Section 3 - Medical Centre information

Your Doctor/Nurse's First Name*:	This field is required.
Your Doctor/Nurse's Last Name:
	Doctor Nurse
Your Medical Centre Name*:	This field is required.
Your Medical Centre Email(if known):	Invalid Email address.

---

Section 4 - How did you hear about Active For Life (GRx)

---

Section 5 - Further Comments

---

I consent to take part in the Active for Life, Green Prescription (GRx) Programme. I have disclosed all relevant medical conditions (including allergies) to the GRx Team. I have read this document and I understand and accept the conditions it contains.

1. I consent to images, photography and video footage of the client taken by official Harbour Sport staff to be used for future Harbour Sport and promotions and events. This consent is given in accordance with the Privacy Act 1993.
2. I agree that the client refers and intends on completing this programme entirely at their own risk.
3. I acknowledge that this programme involves the risk of injury from various causes. I consent to entering the Active for Life (GRx) programme entirely at the client’s own risk.
4. I agree to participate in the Active for Life (GRx) 12-week email campaign.
5. Safety precautions undertaken by the organisers (such as class/programme supervision & client safety briefings) are a service to the client and other clients but are not a guarantee of safety. I acknowledge and accept that while the organisers take reasonable precautions to supervise the client during their attendance at the class/programme, the client is ultimately responsible for their safety.
6. I acknowledge and accept that the client will be fully responsible for the security of their personal belongings at the class/programme.
7. While the organisers will use all reasonable efforts to ensure that the class/programme is conducted as advertised, I acknowledge that by reason of circumstances beyond the control of the event organisers, it may become necessary or desirable to change the form of the class/programme and if that occurs, I consent to the changes and I agree that each and every one of the conditions set out herein shall apply to that changed class/programme.
8. I acknowledge and agree that the client must abide by all participation rules and directions issued by Harbour Sport organiser.

By ticking this, I am indicating that I understood and agree with all the points listed above. *
This field is required.

Submit

There are fields which are required before you can submit this form.