Home
Events
Expand submenu Events
Collapse submenu Events
The Brother Ball
Advance To Alpha
Integrated Essentials
About
Shop
Visit Us
4/4 Hutchinson Street, Burleigh Heads QLD
Site navigation
Home
Events
The Brother Ball
Advance To Alpha
Integrated Essentials
About
Shop
Visit Us
4/4 Hutchinson Street, Burleigh Heads QLD
Cart
Cart
Your cart
Close Cart
Brotherhood Screening Form
Basic Details
First Name
*
Last Name
Email
*
Phone Number
*
Date Of Birth
*
How Did You Hear About Us?
*
Word of mouth
Social Media
Friends/Family
Other
Emergency Contact
First Name
*
Last Name
*
Emergency Contact Number
*
Relationship
What Motivated You To Come Down?
Do You Have Any Friends Or Family Who Would Be Interested In Brotherhood?
Yes
No
Health Questionnaire
What Is Your Fitness Level?
Low
Average
Good
Excellent
Have you ever suffered or been told by a doctor you have suffered a stroke?
*
Yes
No
Do you have, or have you been told by a doctor that you have a heart condition?
*
Yes
No
Do you ever experience unexplained pain in your chest?
*
Yes
No
Are you an asthmatic? If so have you suffered an asthma attach that requires medical attention in the past 12 months?
*
Yes
No
Are you a diabetic? (Type I or Type II)
*
Yes
No
Do you have any diagnosed muscle, bone or joint problems?
*
Yes
No
Have you suffered from any physical injuries in the past 12 months that may be aggravated or effect your ability in our sessions?
*
Yes
No
Please leave any additional information here
Do you consent to being in any photos & videos whilst attending?
*
Yes
No
Are you a healthy human and confident in your ability to participate this event/class?
*
Yes
No
Do you agree to occasionally receive important news and information from Brotherhood via email? We don't send anything you don't care about!
*
Yes
No
Submit
Search
Choosing a selection results in a full page refresh.
Press the space key then arrow keys to make a selection.
Use left/right arrows to navigate the slideshow or swipe left/right if using a mobile device
