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  1. <?php
  2. $date = date("d-m-Y", strtotime("today"));
  3. ?>
  4. <!DOCTYPE html>
  5. <html>
  6. <head>
  7. <meta name="viewport" content="width=device-width, initial-scale=1">
  8. <link href="assets/jquery.signaturepad.css" rel="stylesheet">
  9. <!--[if lt IE 9]><script src="../assets/flashcanvas.js"></script><![endif]-->
  10. <script src="http://ajax.googleapis.com/ajax/libs/jquery/1.5.1/jquery.min.js"></script>
  11. <style>
  12. body {
  13. /* background-color: #EAEAEA; */
  14. }
  15. .main {
  16. width: 700px;
  17. margin: 0 auto;
  18. font-family: "HelveticaNeue-Light", "Helvetica Neue Light", "Helvetica Neue", Helvetica, Arial, "Lucida Grande", sans-serif;
  19. line-height: 16px;
  20. font-size: 13px;
  21. background-color: #FFFFFF;
  22. border-radius: 5px;
  23.  
  24. }
  25. .vars {
  26. margin-top: 110px;
  27. }
  28. header {
  29. /* color: #97C857; */
  30. font-size: 0.9em;
  31. font-weight: 700;
  32. }
  33. header span {
  34. color: #000;
  35. }
  36. .logo {
  37. margin-bottom: 5px;
  38. text-align: right;
  39. width: 220px;
  40. float:right;
  41. }
  42. .highlight-mail {
  43. color: #97C857;
  44. text-decoration: underline;
  45. font-weight: bolder;
  46. }
  47. .footer-text {
  48. /* color: #97C857; */
  49. vertical-align: middle;
  50. font-size: 0.8em;
  51. width:100%;
  52. float: left;
  53. }
  54. .footer-img {
  55. margin: -20 40;
  56. }
  57. .recepient {
  58. font-weight: bold;
  59. color: #000;
  60. }
  61. .knowledge-center {
  62. margin: 0 auto;
  63. display: block;
  64. }
  65. .left_header {
  66. float: left;
  67. }
  68. .right_header {
  69. float: right;
  70. }
  71. .memberdetails
  72. {
  73. width:80% !important;
  74. height: 20px;
  75. }
  76. thead
  77. {
  78. font-weight: bold;
  79. }
  80. textarea
  81. {
  82. width: 99%;
  83. min-height: 50px;
  84. }
  85. .person input
  86. {
  87. padding: 5px 10px;
  88. }
  89. .error
  90. {
  91. border-style: solid;
  92. border-width: 3px;
  93. border-color: red;
  94. }
  95. .medical td {
  96. border: 1px solid black;
  97. padding: 5px;
  98. }
  99. .medical
  100. {
  101. width: 100%;
  102. border: 1px solid black;
  103. border-collapse: collapse;
  104. }
  105. /*
  106. .person td:nth-child(n) {
  107. font-weight:bold;
  108. }
  109. */
  110.  
  111. </style>
  112. </head>
  113.  
  114. <body>
  115. <div class="main container-fluid">
  116. <div class="row">
  117. <header class="text-right" >
  118. <center><img src="logo.png" style="width: 300px;text-align: center"></center>
  119. <h3 style="text-align: center; font-size: 18px;">Participant Information<br>All personal information supplied is confidential**</h3>
  120. </header>
  121. </div>
  122. <table width="100%" class="person">
  123. <tr>
  124. <td width="148">First Name:</td>
  125. <td><?php echo $_REQUEST['firstname'];?></td>
  126. </tr>
  127. <tr>
  128. <td>Last Name:</td>
  129. <td><?php echo $_REQUEST['lastname'];?></td>
  130. </tr>
  131. <tr>
  132. <td>Birthday:</td>
  133. <td><?php echo $_REQUEST['dob'];?></td>
  134. </tr>
  135. <tr>
  136. <td>Address 1:</td>
  137. <td><?php echo $_REQUEST['address1'];?></td>
  138. </tr>
  139. <tr>
  140. <td>Address 2:</td>
  141. <td><?php echo $_REQUEST['address2'];?></td>
  142. </tr>
  143. <tr>
  144. <td>City:</td>
  145. <td><?php echo $_REQUEST['city'];?></td>
  146. </tr>
  147. <tr>
  148. <td>Mobile:</td>
  149. <td><?php echo $_REQUEST['mobile'];?></td>
  150. </tr>
  151. <tr>
  152. <td>Occupation:</td>
  153. <td><?php echo $_REQUEST['occupation'];?></td>
  154. </tr>
  155. <tr>
  156. <td>Email Address:</td>
  157. <td><?php echo $_REQUEST['email'];?></td>
  158. </tr>
  159. <tr>
  160. <td>Doctors Name:</td>
  161. <td><?php echo $_REQUEST['doctorname'];?></td>
  162. </tr>
  163. <tr>
  164. <td>Doctors Phone:</td>
  165. <td><?php echo $_REQUEST['doctorphone'];?></td>
  166. </tr>
  167. <tr>
  168. <td>Emergency Contact:</td>
  169. <td><?php echo $_REQUEST['emergencycontact'];?></td>
  170. </tr>
  171. <tr>
  172. <td>Phone:</td>
  173. <td><?php echo $_REQUEST['emergencycontactphone'];?></td>
  174. </tr>
  175. </table>
  176. <br>
  177. <br>
  178. <table class="medical">
  179. <thead>
  180. <tr>
  181. <td>Have you ever suffered from</td>
  182. <td>Yes/No</td>
  183. <td>If yes, please give details & complete section below</td>
  184. </tr>
  185. </thead>
  186. <tbody>
  187. <tr>
  188. <td>Heart Problems</td>
  189. <td><?php echo $_REQUEST['heartproblems'];?></td>
  190. <td><?php echo $_REQUEST['heartproblemsdetails'];?></td>
  191. </tr>
  192. <tr>
  193. <td>Respiratory Problems<br>1. Asthma<br>2. Other</td>
  194. <td><?php echo $_REQUEST['respiratoryproblems'];?></td>
  195. <td><?php echo $_REQUEST['respiratoryproblemsdetails'];?></td>
  196. </tr>
  197. <tr>
  198. <td>Allergies<br>1. Drugs/ointments<br>2. Insects<br>3. Other</td>
  199. <td><?php echo $_REQUEST['allergies'];?></td>
  200. <td><?php echo $_REQUEST['allergiesdetails'];?></td>
  201. </tr>
  202. <tr>
  203. <td>Diabetes</td>
  204. <td><?php echo $_REQUEST['diabetes'];?></td>
  205. <td><?php echo $_REQUEST['diabetesdetails'];?></td>
  206. </tr>
  207. <tr>
  208. <td>Blood Pressure</td>
  209. <td><?php echo $_REQUEST['bloodpressure'];?></td>
  210. <td><?php echo $_REQUEST['bloodpressuredetails'];?></td>
  211. </tr>
  212. <tr>
  213. <td>Recent Operation</td>
  214. <td><?php echo $_REQUEST['operation'];?></td>
  215. <td><?php echo $_REQUEST['operationdetails'];?></td>
  216. </tr>
  217. <tr>
  218. <td>Epilepsy</td>
  219. <td><?php echo $_REQUEST['epilepsy'];?></td>
  220. <td><?php echo $_REQUEST['epilepsydetails'];?></td>
  221. </tr>
  222. <tr>
  223. <td>Recent Illness</td>
  224. <td><?php echo $_REQUEST['recentillness'];?></td>
  225. <td><?php echo $_REQUEST['recentillnessdetails'];?></td>
  226. </tr>
  227. <tr>
  228. <td>Phobias</td>
  229. <td><?php echo $_REQUEST['phobias'];?></td>
  230. <td><?php echo $_REQUEST['phobiasdetails'];?></td>
  231. </tr>
  232. <tr>
  233. <td>Broken bones or sprains & strains</td>
  234. <td><?php echo $_REQUEST['brokenbones'];?></td>
  235. <td><?php echo $_REQUEST['brokenbonesdetails'];?></td>
  236. </tr>
  237. <tr>
  238. <td>Other</td>
  239. <td>
  240. <?php echo $_REQUEST['other'];?>
  241. </td>
  242. <td><?php echo $_REQUEST['otherdetails'];?></td>
  243. </tr>
  244. <tr>
  245. <td>Have you had your appendix removed?</td>
  246. <td>
  247. <?php echo $_REQUEST['appendix'];?>
  248. </td>
  249. <td><?php echo $_REQUEST['appendixdetails'];?></td>
  250. </tr>
  251.  
  252. <tr>
  253. <td>Can you swim?</td>
  254. <td colspan="2">
  255. <?php echo $_REQUEST['swim'];?>
  256. </td>
  257. </tr>
  258. <tr>
  259. <td>Do you suffer from any existing medical condition,<br> injury or impairments which may impact on any<br>activities you may do?</td>
  260. <td>
  261. <?php echo $_REQUEST['medialcondition'];?>
  262. </td>
  263. <td><?php echo $_REQUEST['medialconditiondetails'];?></td>
  264. </tr>
  265. </tbody>
  266. </table>
  267. <p>NOTE: If you answered yes to the last question, it is your responsibility to ensure you have spoken to your doctor or medical professional to ensure you are medically and physically sound and able to participate prior to commencing any of our programs.</p>
  268. <!--
  269. <p>Do you suffer from any existing medical condition, injury or impairments which may impact on any activities you may do?</p>
  270. <p><?php echo $_REQUEST['medialcondition'];?></p>
  271. -->
  272. <p>If you answered yes to the above question, it is your responsibility to ensure you have spoken to your doctor or medical professional to ensure you are medically and physically sound and able to participate prior to commencing any of our programs.</p>
  273. <p><strong>Medicines</strong>: Please give details of any medicines or medication being carried or being consumed by you including dose, frequency and whether you will have taken any prior to the activities you are registered for with us.</p>
  274. <p><?php echo $_REQUEST['medicines'];?></p>
  275. <p>I agree to pictures/images of me being used for promotional purposes, including but not limited to social media, print, video:</p>
  276. <p><?php echo $_REQUEST['photos'];?></p>
  277.  
  278. <p>**We use all reasonable means to protect the confidentiality of your health, medical and other personal information (together ‘Personal Data’) while in our possession or control. For full information on how we protect your Personal Data, please see our Privacy Policy on our website.</p>
  279. <p><strong>RELEASE OF LIABILITY AND INDEMNITY</strong></p>
  280. <p>I acknowledge that I participate in any activity at my own risk. I understand that my participation in any activity may include the risk of serious injury or even death from various causes including exertion, dehydration, and accidents with surroundings.</p>
  281. <p>I warrant that I am physically and mentally fit to participate safely in the activities that I have registered for.</p>
  282. <p>I release all representatives, employees, directors, affiliates and agents of Shepherd Consulting (Qld) Pty Ltd t/a Women’s Fitness Adventures from any and all liability, including but not limited to direct or indirect, special, consequential loss or injury and including any liability for negligence, claims, demands and proceedings arising out of or connected with my participation in any activity, including any activities organized by any related third party</p>
  283. <p>By signing this Release and Indemnity below, I am confirming that I am suitably fit and healthy to participate in this activity and that a doctor or medical professional has not advised me otherwise. I also confirm that I am 18 years of age or older and that I have read and fully understand these terms. (Alternatively I am the parent or legal guardian of the minor and I agree on behalf of the participant and will agree to indemnify any person, affiliate, representative, and third party providing or involved in the activities on the above terms.)</p>
  284. <p>Agreed and acknowledged</p>
  285. <br/>
  286. <img src="<?php echo $_REQUEST['signature'];?>">
  287. <?php echo $date;?>
  288. </div>
  289.  
  290.  
  291.  
  292. </body>
  293. </html>
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