• Alerts (1) Click to view
    Current alerts 30 April 2024
    • Due to ongoing maintenance issues, the waterslides will be closed until further notice.

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  • What's on (1) Click to view
    What's on today 30 April 2024
    • Senior Social Sports competition in the stadium.

      6:00 PM - 10:00 PM
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  • Opening Hours Click to view
    Today's Opening Hours 30 April 2024
    • Gym (staffed hours)

      5:00 AM - 9:00 PM
    • 50m Outdoor Pool

      5:30 AM - 8:30 PM
    • General Entry and Aquatics

      5:30 AM - 8:30 PM
    • Stadium

      5:30 AM - 4:00 PM
    • Carnaby's Club Crèche

      8:45 AM - 12:45 PM
    • Plunge+Co Café

      6:00 AM - 3:00 PM
    • Waterslides

      Closed

Exercise and Physical Activity Readiness Assessment for Youths

The purpose of this form is to ensure we provide every Youth Active member with the highest level of care.

Physical activity provides an opportunity for youths to have fun and promotes good health and an enhanced quality of life for the future.

However, there are a small number of youths who may be at risk when participating in an exercise/physical activity program. We ask therefore that you complete this questionnaire carefully online, or print and return it to the instructor conducting the fitness appraisal.

Complete the questionnaire



Child Gender:




Heart-Lung-Other systems


1. Does your child have, or has your child had (please tick all that apply):









2. Does your child experience or has your child ever experienced epilepsy or seizures/convulsions?:


If yes, is it at rest or during exercise?:






3. Does your child have, or has your child had, an eating disorder?:


4. Does your child take any medications for (please tick all that apply):









Muscle-Bone system


1. In the last six months, has your child had any muscular pain while exercising?:



Has a doctor treated this pain?:


2. In the last six months, has your child experienced joint pain, or pain in the bones?:



Has this joint pain, or pain in the bone been treated by a doctor?:


3. Has your child broken any bones or suffered injury to their bones in the last 12 months?:


Brain-Muscle system


1. Does your child have, or has your child had difficulty/problems with any of the following (please tick all that apply):







2. Has your child ever experienced a brain or spinal injury?:


3. Does your child experience difficulty in the skill of (please tick all that apply):


Special conditions

1. Does your child use a 'puffer' or 'ventilator' for asthma?:


2. Does your child self-administer insulin for Diabetes?:


3. Does your child have any chronic disabilities or chronic illnesses?:


If yes, please indicate the condition(s):








4. Is your child allergic to food, medications, pollens or other allergens or specific environments?:



5. Does your child follow a special diet?:


6. Has your child ever been diagnosed with a nutritional deficiency (such as non-iron deficiency)?:


General health


1. Has your child had surgery in the previous 12 months?:


2. Are you aware of any medical reason/condition which might prevent your child from participating in an exercise program?:



  • The information provided above regarding my child's health is, to the best of my knowledge, correct.
  • I will inform you immediately if there are any changes to the information provided above.
  • I give permission for my child to commence your physical activity program.
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Cockburn Nyungar moort Beeliar boodja-k kaadadjiny. Koora, yeyi, benang baalap nidja boodja-k kaaradjiny.
Ngalak kaadatj dayin boodja, kep wer malayin. Ngalak kaadatj koora koora wer yeyi ngalang birdiya.

City of Cockburn acknowledges the Nyungar people of Beeliar boodja. Long ago, now and in the future they care for country.
We acknowledge a continuing connection to land, waters and culture and pay our respects to the Elders, past, present and emerging.

Aboriginal and Torres Strait Islander people are warned that this website may contain images and voices of deceased persons.