Adam Russell PT - ICRW & PAR-Q Form

PAR-Q & ICRW Forms
Hello there!

Thank you so much for choosing me to help you and be a part of your fitness journey.

We are just one crucial step away from starting to increase and/or diversify your fitness and activity levels. Being more active is very safe, however, some people should check with their doctor before they undertake a physical activity.

If you are planning to become more physically active, start by carefully completing this Physical Activity Readiness Questionnaire (PAR-Q) in conjunction with reading and approving the Informed Consent and Release & Waiver (ICRW). You must not participate in physical activity in connection with Adam Russell Personal Trainer (“the Trainer”) unless you have completed, signed, and actioned (as necessary) both your PAR-Q and ICRW and have submitted them 24 hours prior to your first session.

See you soon,

Adam
About you

Please complete with your personal, contact and emergency contact information:
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PART 1: Physical Activity Readiness Questionnaire

(PAR-Q)
Questionnaire

Please read and honestly answer YES or NO to the following questions:
1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?*
2. Do you feel pain in your chest when you do physical activity?*
3. In the last month, have you had chest pain when you were not doing physical activity?*
4. Do you lose your balance because of dizziness or do you ever lose consciousness?*
5. Do you have a bone or a joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?*
6. Is your doctor currently prescribing medication (for example, water pills) for your blood pressure, a heart condition or any other condition?*
7. Are you pregnant?*
8. Do you know of any other reason why you should not do physical activity?*
If you answered YES to one or more questions:

You are required to gain written consent from your doctor before participating in an excersise programme. Talk to your doctor about the kinds of acivities you wish to participate in and follow their advice.

If you answered NO honestly to all the above questions:

You can be reasonably sure that you can start becoming more physically active - begin slowly and build up gradually. This is the safest and easiest way to go.

PLEASE NOTE:
- You should delay becoming much more active, if you are not feeling well due to a temporary illness (e.g. cold or fever) and wait until you feel better.
- You should delay becoming much more active, if you are or may be pregnant and talk to your doctor before you start becoming more active.
- If your health changes so that you can then answer YES to any of the above questions, tell your fitness or health professional and consult your doctor.
Your signature

Please sign if you have completed the form above and agree with this statement below:
“I have read, understood & completed this questionnaire. All questions were answered honestly and to my satisfaction.”
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Clear
Date*

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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 seven questions.

NOTE: If the PAR-Q form is being given to a person before he/she participates in a physical activity programme or fitness appraisal, it may be used for legal or administrative purposes.

Informed Use of Form: Adam Russell Personal Trainer assumes no liability for persons who undertake physical activity. If in doubt after completing this questionnaire, consult your doctor prior to physical activity.

PART 2: Informed Consent and Release & Waiver Form

(ICRW)
Statement & Questionnaire

Please read below statement and honestly answer I AGREE or I DO NOT AGREE to questions that follow:
Description of physical activity to be undertaken

I understand that I will be taking part in physical activity that may challenge my cardio respiratory system (heart and lungs), musculoskeletal system (muscle endurance, strength and flexibility) and nervous system.

Physical activity may include but shall not be limited to aerobic and/or anaerobic activities, callisthenic exercises, weight-bearing movements or resistance training exercises with equipment, flexibility exercises and stability exercises.

I agree that if I require further information relating to the nature or intensity of the physical activity I will be undertaking and the possible effect on my body, I will seek further advice and by signing this ICRW I confirm that I am satisfied with my understanding of the nature and intensity of the physical activity I will be undertaking.

Potential Risk

I understand that the physical activity I am taking part in carries an inherent risk of serious injury, disability, paralysis and possible death and I am electing voluntarily to participate in the physical activity knowing it may be hazardous to me and my property. I voluntarily assume full responsibility for any risks or loss, property damage or personal injury (including death) that may be sustained by me, or loss or damage to property owned by me, as a result of participation in the physical activity.

I understand that the reaction of the body to physical activity cannot always be predicted with accuracy. I know there is a risk of musculoskeletal strains, pain and injury, and that certain abnormal changes may occur during or following physical activity which may adversely affect blood pressure or cause strokes, heart attacks or even death.

I accept it is my responsibility to make the appropriate people aware of my medical condition by completing, signing and (where relevant) updating my PAR-Q. I understand it is my responsibility to recognise when I am experiencing undue discomfort or fatigue and to omit or discontinue the physical activity as necessary.

Release of liability, waiver of claims and indemnity

I understand that the Trainer shall not be liable for any damages to my property or to me as a result of any personal injury arising from my participation in the physical activity which is undertaken entirely at my own risk.

In consideration of the Trainer allowing me to participate in the physical activity (which I accept as good and sufficient consideration), I agree:-
1. To waive any and all claims that I have or may in the future have against the Trainer arising out of my participation in the physical activity including but not limited to liability arising from the negligence or fault of the Trainer for my death, disability, personal injury, property damage or property theft*
2. To fully and forever release and discharge the Trainer from any and all liability for any loss, damage, right of action, expense or injury including death that I may suffer as a result of my participation in the physical activity due to any cause whatsoever including negligence (other than gross negligence), breach of contract or breach of any statutory or other duty of care on the part of the Trainer. *
3. To hold harmless and indemnify the Trainer from any and all liability for any property damage or personal injury to any third party, resulting from my acts or omissions whether or not I was participating in physical activity at the time the cause of action arose. *
4. That this ICRW shall not apply in the event of gross negligence on the part of the Trainer leading to my personal injury or death but otherwise it shall be construed broadly to provide a release and waiver to the fullest extent permitted by law.*
5. Consent to receive medical treatment which may be deemed advisable in the event of injury, accident or illness during the physical activity.*
6. I understand that any oral or written representation made by the Trainer regarding the safety of the physical activity is overridden by this ICRW.*
7. This ICRW shall be effective and binding on my heirs, next of kin, executors, administrators, assigns and representatives in the event of my death. *
Your signature

This ICRW is governed by the laws of and the exclusive jurisdiction of the courts of England and Wales. Please sign if you have completed the form above and agree with this statement below:
"I confirm that I have read and fully understand the terms and effect of this ICRW which is that I am waiving certain legal rights which I or my heirs and those referred to in Paragraph 7 may otherwise have against the Trainer."
Signature*

Clear
Date*

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PAR-Q & ICRW Forms

About you

PART 1: Physical Activity Readiness Questionnaire

Questionnaire

Your signature

“I have read, understood & completed this questionnaire. All questions were answered honestly and to my satisfaction.”

PART 2: Informed Consent and Release & Waiver Form

Statement & Questionnaire

Your signature