Worksheet

Par-Q

Participant Activity Readiness Questionnaire & Liability Waiver

1.

Today's date

2.

Please tick YES to confirm that I have your permission to record and store this information electronically.

3.

Contact Information

Full Name

4.

Email Address

5.

Please tick to confirm that I have your permission to contact you via email and send newsletters

6.

Emergency Contact Information

Please Write the name and number of your emergency contact

7.

Date of Birth

8.

Do you exercise regularly?

9.

If not, how long is it since you last exercised?.

10.

Medical Information

Do you have or have you ever experienced the following? Check the boxes that apply to you

11.

If you checked any boxes on the previous question and want to write any further notes please do so here...

12.

Do you have or are you currently suffering from any of the following? Check boxes that apply to you...

13.

If you checked any boxes on the previous question and want to write any further notes please do so here...

14.

Are you taking any medication?

15.

If so, what medication?

16.

Pregnancy

Are you pregnant? or

Have you had a baby in the last six months? 

17.

If so, please elaborate on how many week pregnant you are or any other relevant information...

18.

You should always consult your doctor or other healthcare provider before starting an exercise program. Is there any reason not mentioned above why a fitness class may not be suitable for you? If so, please give details here

19.

Liability Waiver

I understand that there is a risk of injury associated with participating in any exercise class and hereby assume full responsibility for any and all injuries, losses and damages that I incur while attending, exercising or participating in classes. I hereby waive all claims against the instructor individually or otherwise, for any and all injuries, claims or damages that I might incur.

Please Check the box below to confirm you have read and understood the Liability waiver and have provided honest and up to date medical information.