Physical Activity Readiness Questionnaire (PARQ)
If you are between the ages of 14 and 69, the PAR-Q will tell you if you should check with your doctor before you significantly change your physical activity patterns. If you are over 69 years of age and are not used to being very active, check with your doctor. Common sense is your best guide when answering these questions. Please read carefully and answer each one honestly. Please check the box either YES or NO.
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Full name *
Email *
Address *
Phone number *
Emergency contact (Name and number) *
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *
Do you feel pain in your chest when you do physical activity? *
In the past month, have you had chest pain when you were not doing physical activity? *
Do you lose your balance because of dizziness or do you ever lose consciousness? *
Have you ever suffered with photo-sensitive epilepsy? (Dance fitness classes have disco lights) *
Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in physical activity? *
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? *
Are you pregnant or have you had a baby in the last six months? *
Do you know of any other reason why you should not do physical activity? If 'YES' please leave a comment below (otherwise leave a 'N/A'): *
Please add any medical information here if you wish to.
If you have answered YES to any of the above questions, then you are required to gain consent from your doctor before participating in the group exercise session. By checking this box you are stating that you have sought medical advice and that your GP has agreed you may attend these classes.                                                                                                                                                             *
Required
If you have answered NO to all of the above questions you can be reasonably sure that it is safe to participate in physical activity, gradually building up from your current ability level.                                                                                            You are advised to postpone entry into the programme if you feel unwell or have a temporary illness. You must inform your instructor of any changes to your health status, whilst engaged in your exercise sessions. *
Required
You should not attend an in-person class  if you or anyone you have been in contact with has tested positive or had symptoms of COVID 19 within the last 14 days. These symptoms include a persistent cough, a high temperature (above 37.8°C), or a change or loss of taste/smell. It is advised that you self-isolate and arrange for a COVID 19 test as soon as possible.                                                                                                                                                                  You should not attend an in-person class if you are currently awaiting the results of a COVID test. Even if you have no symptoms and the test was simply precautionary, please do not attend a class until after you have received a negative result.                                                                                                      You should not attend an in-person class  if you or anyone in your household classes as a vulnerable person.                                                                                                           You consent to inform your instructor if you or any member of your household has developed any symptoms of COVID 19, if you have been to a class within the past 14 days. This may include any of the following symptoms: a persistent cough, a high temperature (above 37.8°C), or a change or loss of taste/smell. It is advised that you self-isolate and arrange for a COVID 19 test as soon as possible. You will update us of your result so we can notify people who may have had contact with you. *
Required
Please note that no liability is accepted for any loss of or damage to any articles, which you may bring with you to classes. Equally, liability is not accepted for loss of or damage to motor vehicles or their contents and these are left at the owner’s risk. *
Required
I agree to my personal contact information being used to send me important class updates and other relevant updates, news, offers and class social events. IMPORTANT: If you do not tick this box I will be unable to let you know about changes to classes, cancellations etc. You can unsubscribe at any time. This information will be stored in line with the General Data Protection Regulation (GDPR) and the Privacy Policy of ‘Clubbercise & Zumba with Accidental Fitness Buxton’ and ‘Accidental Yogis’ as part of Accidental Fitness. *
Required
I have read, understood and accurately completed this questionnaire. I confirm that I am voluntarily engaging in an acceptable level of exercise, and that my participation involves a risk of injury. I understand that my instructor will not be held responsible for any accident or sustained injury unless due to negligence.                                                                                                                                 Note: This physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes so that you would answer YES to any of the health related questions.                                                                                                                            Customer signature (print name) and today's date. *
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