St. Columba's Church Hall, Plas Newton, Chester, Cheshire, CH2 1SA, Tel: 01244 535788

Registered Charity 1123789

Gym Induction Form

To be completed by a Representative of Chester Heart Support Group and retained in Gym Records File

Contact Details

Discharge forms received from Countess of Chester Hospital:



Letter from Doctor:



Programme cannot be commenced until discharge details have been received

 Signature of Lache Representative

Attended Lache Code of Practice induction:


Hold/drag mouse to draw signature

 Signature of participant 

Attended exercise suite familiarisation induction:

I confirm that I have received a copy of the “Lache Guidance Notes for people using the Lache Community Centre Gym” and agree to comply with the rules listed and adhere to the programme guidance contained.