Health Questionnaire & Par-Q

Request edit access

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Health Questionnaire & Par-Q

We are so excited to have you join our Boxing Boot-camp

For your convenience, all of our initial "paperwork" is included below. The following online form should take you less than 10 minutes to complete.

Upon receiving your completed form an email will be sent to you with further information and payment details (please allow 24/48 hours for this, and be sure to check your spam folder).

If you have any questions please email me directly at: donna@dl-training.co.uk

Email *

PART 1: PERSONAL INFORMATION

Full Name *

Address *

Phone Number *

Date of Birth *

YYYY

PART 2: PAR-Q

This form acts as a PAR-Q (Physical Activity Readiness Questionnaire) that will help determine whether or not it's safe for you to begin this exercise program. Please answer the following questions honestly, and provide as much detail as possible where applicable.

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
*

Yes

Do you feel pain in your chest when you do physical activity?
*

Yes

In the past month, have you had chest pain when you were not doing physical activity?
*

Yes

Do you lose your balance because of dizziness or do you ever lose consciousness?
*

Yes

Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?
*

Yes

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
*

Yes

Do you know of any other reason why you should not do physical activity?
*

Yes

If you answered YES to the previous question, please explain in detail here:

PART 3: COACHING AGREEMENT

With the help as your Boxing Boot-camp Instructor, you are going to greatly improve your ability to accomplish your health goals faster, safer, and with maximum benefits. Plus, the tools and strategies you will learn during our time working together can be used for a lifetime.

The following expectations must be met with regards to our sessions:

1. Sessions are paid monthly in advance at the fee advertised. This will be collected on the 1st of every month. After first invoiced payment is cleared a standing order is advised to avoid late payment so entry is allowed for the next months sessions.

2. Boxing gloves are provided but if you prefer to use your own then this is fine.

3. Clients must arrive in time to complete the warm up session. Clients arriving late to a session will gain entry at the trainers discretion, unless other arrangements have been previously made.

4. There is no time commitment in this program. To end your subscription, simply provide written notice (email) at least 30 days in advance (excluding trial month).

5. No refunds will be issued for any reason.

6. You agree for photos/videos to be shared for marketing purposes.

7. I understand that it is my obligation to inform my trainer of any symptoms such as fatigue, shortness of breath or chest discomfort or any injuries or health conditions that have arisen since filling out the PAR-Q.

8. I understand that my instructor is not a doctor, physiotherapist or dietitian and the advice offered is optional and not a replacement for professional advice from experts within said specialist fields.

I have read the above Coaching Agreement and agree to its terms:
*

Yes

Required

PART 4: WAIVER OF LIABILITY

It's important that you understand that any form of physical exercise can be strenuous and subject to risk of injury. You are urged to obtain a physical examination from a doctor before participating in any exercise activity, including those provided by your instructor

You agree that if you engage in any physical exercise or activity, you do so entirely at your own risk. This waiver and release of liability includes, without limitation, all injuries which may occur as a result of: (a) your participation in any activity or participation in any exercise routine and (b) instruction, training, supervision, or dietary recommendations by your instructor.

You acknowledge that you have carefully read this “waiver and release” and fully understand that it is a release of liability. You expressly agree to release and discharge your instructor from any and all claims or causes of action and you agree to voluntarily give up or waive any right that you may otherwise have to bring a legal action against your instructor for personal injury or property damage. By signing this release, you acknowledge and understand its content and that this release cannot be modified orally.

I have read the above Waiver of Liability and agree to its terms:
*

Yes

Required

PART 5: FINAL THOUGHTS & SIGNATURE

Is there anything else you'd like to share? If so, please do so here:

I agree that all information provided on this form is accurate to the best of my knowledge:
*

I Agree

Required

Type your full name here as your digital signature:
*

Date:
*

YYYY

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Forms