Membership Form

To become a Wild Women on Top Member we need to gather some important information about you and your adventure fitness goals! To help us do this, we have created a Membership Form which covers your exercise history, current goals, medical history and much more! Once you have filled out a Join Now form online, please make sure you complete the Membership Form and Risk Waiver and send to us with the appropriate Medical clearance (if required) before commencing your training with WWoT.

Thank you!

Please note that YOU MUST complete ALL sections and return to WWoT before commencing this program, along with a Risk Waiver.

Important! You are required to obtain medical clearance from a doctor if:
• you answer YES to any of the questions in part E of this form;
• you are over 55yrs; or
• if you are an On-line Member requesting an online training program

Please ask your Doctor to complete a Medical Clearance Form (available for download here) and return this to WWoT prior to commencing training.

Name*

Mobile Number*

Email*

Date of Birth*

(DD/MM/YYYY)

If you are a Trek Training Member which Group will you be training in?

Select ... Mon Middle Harbour Mod Squad 7.30pm Mon Upper North Shore Mod Sq 9.30am Mon Bondi Mod Squad 7.30pm Tues Mosman Mod Squad 9.30am Tues Lower N Shore Newbies 7.30pm Wed Manly Mod Squad 7.30pm Wed Inner West Newbies 7.30-9.30pm Thurs North Shore Mod Squad 7.30pm Fri Manly Mod Squad 9.30am Fri E Suburbs Newbies 9.30am Interstate / Online Member

Part A: Please indicate what you hope to achieve by becoming a member of Wild Women on Top (hold SHIFT key to choose multiple)*

Reduce stress A challenging goal A team wilderness experience Reduce body fat / generally tone up Do something for me Improve aerobic capacity Have a training goal

Part B: If you have been exercising recently, please give details of frequency, intensity and type

Part C: Which WWoT activties most appeal to you? (Multi select by holding the SHIFT key)*

Wild Walks Wild Weekenders Overseas adventures Trekking with full pack Trekking with day pack Newbies Mountaineering Charity endurance challenges

Part D: Have you ever had any injury, illness, back or joint condition that may be aggravated by strenuous exercise? If yes, please give details*

Part D: Are you now or have you recently been pregnant? Please provide details.*

Part D: Is there any other medical condition that might be reason to modify your exercise plans? If yes, please outline*

Part D: Do you smoke more than two cigarettes a day?*

Yes No

Part D: Have you had any allergies or reactions to any medical drugs or food? If yes, please give details and medication taken.*

Part E: During the last five years have you suffered any significant or recurrent illness or have you been hospitalized?*

Yes No

Part E: Please list any medications you take on a regular basis*

Part E: Have you had any of the following medical conditions?*

None High blood pressure or any heart condition? Asthma, Diabetes, or Epilepsy? Depression, Anxiety or Mental disorder? Do you have any family members who have had heart problems prior to age 60?

Part E: Is there any other medical condition that we should be aware of? If yes, please provide details*

Initials*

Today's Date*

(DD/MM/YYYY)

I, the applicant, acknowledge that I have read and understood and agree to abide by the Terms & Conditions, and the Golden Rules of Wild Women on Top which can be found on the website*

YES

Verify*