PAR-Q

Full Name*

First NameLast Name

Date of Birth*

Date

Mobile Phone Number*

Country Code Mobile Number

Email*

example@example.com

Address*

Street Address

Street Address Line 2

TownCounty

Post Code

Emergency Contact*

First NameLast Name

Relationship:

Phone Number*

Area CodePhone Number

Please read the following questions carefully and check (X) next to the appropriate answers. Answer all questions honestly and to the best of your ability.

YES/ NO*

	Yes	No
Has your doctor ever said that you have a heart condition (had a stroke, heart attack, or heart surgery) and/ or 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 been told by a doctor that you have bone, joint, or muscle problems that could be made worse by physical activity?
Do you have a diagnosed illness that could be made worse by physical activity?
Is your doctor currently prescribing medication for your blood pressure or heart condition?
Have you had a recent surgery?
Are you currently on any medications, either prescription or non-prescription, on a regular basis?
Do you have any allergies?
Are you currently having any physio or orthopedic treatment?
Do you know of any other reason why you should not do physical activity?

If you have answered 'Yes' to any of the above, please provide further details :

Current exercise? *

Give details

Occupation:*

What are your motivating factors for joining? *

How did you hear about Pole Affinity? *

Photo / video consent for use in our social media/ web/ advertising.

If no please state here. You may withdraw your consent at any time

Fitness Participation Agreement

I have answered the questions above to the best of my ability and affirm that my physical condition is good and I have no known conditions that would prevent me from participation. I acknowledge that participation is at my own pace and comfort level and that I may discontinue my participation in the sessions at any time. Furthermore, I agree to self-determine my exertion through good judgement and to discontinue any activity that exceeds my personal limitations. I understand that by signing this agreement that I hereby waive and release Pole Affinity & instructors, in any way from liabilities or demands as a result of injury, loss, or adverse health conditions as a result of my participation. I affirm that I have read and understand this document and I wish to participate in fitness activities.

Signature of Participant:*

Date*

Date

Marketing Permissions

Email

Which classes are you interested in?*