Mickey Bushell Gold Standard Academy - Application and PAR-Q
Physical Activity Readiness Questionnaire and Mickey Bushell Gold Standard Academy application form

For most people, physical activity should not pose any problem or hazard. The PAR-Q is designed
to identify the small number of people for whom physical activity might be inappropriate or those
who should seek medical advice concerning the type of activity most suitable for them.

The questions asked below will help us to identify whether the 8 week academy course will be suitable for you.

IT IS IMPERATIVE THAT YOU ANSWER ALL QUESTIONS HONESTLY
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Email *
Are you a permanent or part-time wheelchair user? *
Which course are you applying for? 
See www.mickeybushell.com for full course details.
ALL COURSE DELEGATES MAY QUALIFY FOR PARTIAL/FULL FUNDING
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How long have you been a wheelchair user? *
Do you have a bone or joint problems such as arthritis? 
If YES, click other and add details
 *
To your knowledge, do you have high or low blood pressure?
If YES, click other and add details
 *
Do you have diabetes mellitus or any other metabolic disorder?
If YES, click other and add details
 *
Has your doctor ever said that you have raised cholesterol? (serum level above 6.2mmol/L)
If YES, click other and add details
 *
Do you have/have ever suffered a heart condition / is there any history of coronary heart disease in your family?
If YES, click other and add details
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Have you ever felt pain in your chest when you do physical
exercise?
If YES, click other and add details
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Is your doctor currently prescribing you drugs or medication? (For either physical or mental health)
If YES, click other and add details
 *
Have you ever suffered from shortness of breath at rest or with mild exercise?
If YES, click other and add details
 *
Do you ever feel faint, have spells of dizziness or have ever lost consciousness?
If YES, click other and add details
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Are you, or is there any possibility that you might be pregnant? 
If YES, click other and add details
 *
Do you suffer from epilepsy?
If YES, click other and add details
 *
Do you have any blood borne diseases; hepatitis, HIV?
If YES, click other and add details
 *
Do you have any skin conditions; eg, dermatitis?
If YES, click other and add details
 *
Does the number 11 come before number 12?
If YES, click other and add details
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Do you have any past medical conditions or injuries which may cause you any issues while participating in the training?
If YES, click other and provide as much information as possible.
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Do you know of any other reason why you should not participate in a programme? Including, but not limited to, previous or ongoing mental or physical health conditions?
If YES, click other and add details
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What would you like to get out of your time with the Academy? 
Is there anything particular that you would like to learn or improve? What do you currently struggle with? 
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On a scale of 1-10 how satisfied are you with your life currently? (Where 1 is not at all and 10 couldn't be better) *
On a scale of 1-10 how happy did you feel in the last month? (Where 1 is not at all and 10 couldn't be better) *
To what extent do you agree with the statement, I can achieve most of the goals that I set myself.
(Where 1 is not at all and 10 completely)
 *
If you have not already done so, consult with your doctor by telephone or in person before increasing your physical activity. Inform your doctor of the questions that you answered ‘yes’ to on the PAR-Q or present your PAR-Q copy. 
After medical evaluation, seek advice from your doctor as to your suitability for the activity you wish to undertake.

PLEASE CONFIRM THAT YOU UNDERSTAND THIS STATEMENT
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Assumption of risk
I hereby state that I have read, understood the information above and answered honestly the questions. I also state that I wish to participate in activities, which include aerobic exercise,
resistance exercise and stretching. 
I realise that my participation in these activities involve risk of injury. I hereby confirm that I am voluntarily engaging in exercise, which has been recommended to me.

PLEASE CONFIRM THAT YOU UNDERSTAND THIS STATEMENT
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Use of my personal data
By submitting this form I consent to Mickey Bushell Gold Standard Academy collecting and storing the personal data that I have provided in this form. 
I acknowledge that this personal data will be handled in accordance with Mickey Bushell Gold Standard Academy privacy policy and it is necessary for them to have it
to ensure my coaching is carried out safely. 

I understand that I may withdraw my consent for use of this data at any time. But that, if I do so, will not be allowed to participate in the coaching.

The submission of this form means you have understand the above, agree to take part in the coaching and are aware of any risks that could occur.

PLEASE CONFIRM THAT YOU UNDERSTAND THIS STATEMENT
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The completion of the this form does not guarantee your acceptance onto the Mickey Bushell Gold Standard Academy. 
Further to the above questions, you will be contacted to arrange a meeting to access your suitability for safe participation on the course.

Please confirm below that you are happy to take part in the meeting, refusal to do so negates your application.
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ACKNOWLEDGEMENT OF UNDERSTANDING

I have read this agreement and fully understand its terms. I understand that I am limiting my rights, including my right to sue. I further acknowledge that I am signing this Agreement freely and voluntarily.

In signing this Agreement, I acknowledge that I agree and accept the terms above and I am voluntarily taking part in the coaching.

SIGNATURE
By writing your full, legal name (as displayed on your passport, driving license or any other government issued identification), you are taken to have signed this form.
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Date of application   (DD/MM/YY) *
Please provide a contact mobile number
Date of birth  (DD/MM/YY) *
Where are you based? (Closest city)
Please add info@mickeybushell.com to your safe sender list.
Your email may end up in Junk/Spam otherwise! 
 *
Required
A copy of your responses will be emailed to the address you provided.
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