Physical Activity Readiness Questionnaire (PAR-Q)
Taking part in physical activity/exercise is very safe for most people. However, some people should check with their doctor before they start an exercise session. Before taking part in physical activity and/or exercise, please answer the questions below. If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor.

Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly: please check YES or NO.

Email address *
1. Has your doctor ever said that you have a heart condition and that you should only do physical activity/exercise recommended by a doctor? *
Required
2. Is there any history of heart disease in your family? *
Required
3. Do you feel pain in your chest when you do physical activity/exercise? *
Required
4. In the past month, have you had chest pain when not doing physical activity/exercise? *
Required
5. Do you lose your balance because of dizziness or do you ever lose consciousness? *
Required
6. Do you have a bone or joint problem (for example; back, knee, or hip) that could be made worse by change in your physical activity? *
Required
7. Do you suffer from any of the following: asthma, diabetes, epilepsy, high blood pressure? (If yes, please give details at end of form) *
Required
8. Do you have any current injuries or conditions, and if so, are they being treated by a doctor or other health professional such as a physical therapist? (If yes, please give details at end of form) *
Required
9. Do you know of any other reason why you should not do physical activity/exercise?
Your answer
If you answered YES to any of the questions above, please explain below and check with a member of the staff before taking part in the physical activity or exercise session. It may be necessary for you to be referred to your doctor before taking part in the session.
Your answer
If you answered NO to all questions, you can be reasonably sure that you can safely take part in the physical activity or exercise sessions, but please ensure that you begin slowly, warm up appropriately and progress slowly.
Your answer
NOTE: You should be able to swim or at the very least be confident in water to take part in a Floatfit® exercise class.
Assumption of Risk
I declare that I have read, understood, and answered honestly all the questions above. I am agreeing to participate in the exercise session (which may include aerobic, resistance, power, and stretching exercises) and I understand that there may be risks associated with physical activity.
"I have read, understood, and completed this questionnaire. Any questions I had were answered to my full satisfaction."
Waiver & Release of Liability
In consideration of the risk of injury while participating in Floatfit® (the "Activity"), and as consideration for the right to participate in the Activity, I hereby, for myself, my heirs, executors, administrators, assigns, or personal representatives, knowingly and voluntarily enter into this waiver and release of liability and hereby waive any and all rights, claims or causes of action of any kind whatsoever arising out of my participation in the Activity, and do hereby release and forever discharge Likewise Fit(Likewise Enterprises, LLC)/Tiffany Van Drimlen/NAC (by association), class located at 1 Whitecliffs Dr, Newport Beach, CA , their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns, for any physical or psychological injury, including but not limited to illness, paralysis, death, damages, economical or emotional loss, that I may suffer as a direct result of my participation in the aforementioned Activity, including traveling to and from an event related to this Activity. I AM VOLUNTARILY PARTICIPATING IN THE AFOREMENTIONED ACTIVITY AND I AM PARTICIPATING IN THE ACTIVITY ENTIRELY AT MY OWN RISK. I AM AWARE OF THE RISKS ASSOCIATED WITH TRAVELING TO AND FROM AS WELL AS PARTICIPATING IN THIS ACTIVITY, WHICH MAY INCLUDE, BUT ARE NOT LIMITED TO, PHYSICAL OR PSYCHOLOGICAL INJURY, PAIN, SUFFERING, ILLNESS, DISFIGUREMENT, TEMPORARY OR PERMANENT DISABILITY (INCLUDING PARALYSIS), ECONOMIC OR EMOTIONAL LOSS, AND DEATH. I UNDERSTAND THAT THESE INJURIES OR OUTCOMES MAY ARISE FROM MY OWN OR OTHERS' NEGLIGENCE, CONDITIONS RELATED TO TRAVEL, OR THE CONDITION OF THE ACTIVITY LOCATION(S). NONETHELESS, I ASSUME ALL RELATED RISKS, BOTH KNOWN OR UNKNOWN TO ME, OF MY PARTICIPATION IN THIS ACTIVITY, INCLUDING TRAVEL TO, FROM AND DURING THIS ACTIVITY. I agree to indemnify and hold harmless Likewise Fit(Likewise Enterprises, LLC)/Tiffany Van Drimlen/NAC (by association) against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney's fees and any related costs, if litigation arises pursuant to any claims made by me or by anyone else acting on my behalf. If Likewise Fit/Tiffany Van Drimlen incurs any of these types of expenses, I agree to reimburse Likewise Fit/Tiffany Van Drimlen. I acknowledge that Likewise Fit/Tiffany Van Drimlen and their directors, officers, volunteers, representatives and agents are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Likewise Fit(Likewise Enterprises, LLC)/Tiffany Van Drimlen/NAC (by association). I ACKNOWLEDGE THAT THIS ACTIVITY MAY INVOLVE A TEST OF A PERSON'S PHYSICAL AND MENTAL LIMITS AND MAY CARRY WITH IT THE POTENTIAL FOR DEATH, SERIOUS INJURY, AND PROPERTY LOSS. The risks may include, but are not limited to, those caused by terrain, facilities, temperature, weather, lack of hydration, condition of participants, equipment, vehicular traffic and actions of others, including but not limited to, participants, volunteers, spectators, coaches, event officials and event monitors, and/or producers of the event. I ACKNOWLEDGE THAT I HAVE CAREFULLY READ THIS "WAIVER AND RELEASE" AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. I EXPRESSLY AGREE TO RELEASE AND DISCHARGE Likewise Fit(Likewise Enterprises, LLC)/Tiffany Van Drimlen/NAC (by association) AND ALL OF ITS AFFILIATES, MANAGERS, MEMBERS, AGENTS, ATTORNEYS, STAFF, VOLUNTEERS, HEIRS, REPRESENTATIVES, PREDECESSORS, SUCCESSORS AND ASSIGNS, FROM ANY AND ALL CLAIMS OR CAUSES OF ACTION AND I AGREE TO VOLUNTARILY GIVE UP OR WAIVE ANY RIGHT THAT I OTHERWISE HAVE TO BRING A LEGAL ACTION AGAINST Likewise Fit/Tiffany Van Drimlen FOR PERSONAL INJURY OR PROPERTY DAMAGE
To the extent that statute or case law does not prohibit releases for negligence, this release is also for negligence on the part of Likewise Fit(Likewise Enterprises, LLC)/Tiffany Van Drimlen/NAC (by association), its agents, and employees. In the event that I should require medical care or treatment, I agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance. In the event that any damage to equipment or facilities occurs as a result of my or my family's willful actions, neglect or recklessness, I acknowledge and agree to be held liable for any and all costs associated with any actions of neglect or recklessness. This Agreement was entered into at arm's-length, without duress or coercion, and is to be interpreted as an agreement between two parties of equal bargaining strength. Both the Participant, _(name appearing below), and Likewise Fit(Likewise Enterprises, LLC)/Tiffany Van Drimlen/NAC (by association) agree that this Agreement is clear and unambiguous as to its terms, and that no other evidence will be used or admitted to alter or explain the terms of this Agreement, but that it will be interpreted based on the language in accordance with the purposes for which it is entered into. In the event that any provision contained within this Release of Liability shall be deemed to be severable or invalid, or if any term, condition, phrase or portion of this agreement shall be determined to be unlawful or otherwise unenforceable, the remainder of this agreement shall remain in full force and effect, so long as the clause severed does not affect the intent of the parties. If a court should find that any provision of this agreement to be invalid or unenforceable, but that by limiting said provision it would become valid and enforceable, then said provision shall be deemed to be written, construed and enforced as so limited.
I, the undersigned participant, affirm that I am of the age of 18 years or older, and that I am freely signing this agreement. I certify that I have read this agreement, that I fully understand its content and that this release cannot be modified orally. I am aware that this is a release of liability and a contract and that I am signing it of my own free will.
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