Zumba with Rose - participant screening form

ADULT (16 years+) PRE-EXERCISE SCREENING TOOL
This screening tool does not provide advice on a particular matter, nor does it substitute for advice from an appropriately qualified medical professional. No warranty of safety should result from its use. The screening in no way guarantees against injury or death.

No responsibility or liability whatsoever can be accepted by Zumba with Rose, Rose Dangaard or her associates, for any loss, damage or injury that may arise from any person acting on any statement or information contained in this tool.

The aim of this COMPULSORY form is to identify those individuals with a known disease, conditions, or signs or symptoms of disease, who may be at a higher risk of an adverse event during physical activity/exercise and have them seek their own medical advice before undertaking Zumba with Rose.

This tool is self administered and self evaluated. Please answer it honestly. The completed form will be held in confidence until no longer needed. You may print a copy for your own reference if you wish.

It must be completed BEFORE you participate in classes.
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mobile Phone Number*
Landline Phone Number (only if no mobile)
E-mail*

Confirmation Email
MEDICAL HISTORY
1. Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?*
2. Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?*
3. Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?*
4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?*
5. If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months? *
6. Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?*
7. Are you pregnant or have you given birth within the last 12 months?*
8. Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise*
IF YOU HAVE ANSWERED 'YES' to any of the 8 questions, please seek guidance from your GP or allied health professional BEFORE undertaking Zumba with Rose activities. Please advise Rose on Rose.Dangaard@hotmail.com or by text/photo message to 0403 161763 of the results of such guidance.

IF YOU ANSWERED ‘NO’ to all of the 8 questions, and you have no other concerns about your health, you may proceed to undertake the class but at all times moderate your participation intensity according to your own personal fitness level.
I believe that to the best of my knowledge, all of the information I have supplied within this tool is correct.
Write your name here to sign in agreement with above*
If you are under the age of 18 please have your parent or guardian sign on your behalf.

LIABILITY WAIVER AND RELEASE

Please read carefully before submitting.
By participating in any class provided by Rose Dangaard (the Instructor) you consent to, and agree to release the Instructor from liability according to these terms. Unless the Instructor notifies you otherwise, this waiver and release will apply to all online or Face-to-Face classes undertaken by you with the Instructor.

You acknowledge that:
1. You are over 16 years of age;
2. You understand that the classes are a form of physical activity and that there are inherent risks in undertaking any form of physical exercise;
3. Via the screening tool, you have disclosed any pre-existing conditions that may place you at a higher risk of injury or inhibit your ability to participate in a class. If you have answered YES to any question then you agree to seek guidance on participating from your health professional BEFORE undertaking any class with the Instructor;
4. If your health circumstances change so that your answer to any of the questions changes to YES, you agree to seek guidance to participate from your health professional BEFORE undertaking any FURTHER class with the Instructor;
5. You will notify the Instructor if you experience any pain throughout the class and will immediately stop participating in the class if requested by the Instructor to do so; If you are participating in an online class that you will seek immediate first aid support in your own location;
6. At the Instructor’s sole discretion, the Instructor may decide not to allow you to participate in a class, or may require you to provide a medical certificate affirming that you are able to participate in a class before allowing you to join;
7. Recommendations or instruction provided by the Instructor may not be tailored for your particular skill or ability level and it is your responsibility to assess whether you are able or want to participate in all or part of a class -- in short you need to pace yourself in the class according to your current fitness level;
8. You are solely responsible for ensuring that your physical environment and clothing, including footwear, is suitable for your participation in any class;
9. You will remain hydrated during classes;
10. If doing an online class you will maintain your exercise space to be free of trip hazards and suitable for the class;
11. Classes may be recorded for by the Instructor for quality control, as well as promotional purposes. If you do not consent to the Instructor using video or still images taken during the class for promotional purposes, please notify the Instructor in writing.
12. To the extent permitted at law, you release and hold the Instructor (and where applicable, directors, employees and representatives) harmless from any liability, cost, expense, damages or claims (including claims of negligence) arising from or which may be suffered or incurred in connection with your participation in any classes provided by the Instructor.
Write your name here to sign in agreement with above liability waiver and release*
If under the age of 18 please have your parent or guardian sign on your behalf.

Should be Empty:

ADULT (16 years+) PRE-EXERCISE SCREENING TOOL