Circus WOW Waiver and Pre-Exercise Screening Form

CIRCUS WOW CONSENT FORM & PRE-EXERCISE SCREENING FORM

This screening form does not provide advice on a particular matter, nor does it subsitute for advice from an appropriately qualified medical professional. No warranty of safety should result from its use. The screening system in no way guarantees against any injury or death. No responsibility or liability whatsoever can be accepted by Circus WOW for any loss, damage or injury that may arise from any person acting on any statement or information contained in this form.
Name*

First NameLast Name
Mobile Number*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
In attending WOW Activities, I agree to:
- notify trainers/coordinators of anything that may impact on my ability to participate safely in training, including physical injuries, medical and/or psychological conditions, and to seek appropriate medical advice prior to participating.
- Take full responsibility for my safe participation in Circus WOW activities. This includes training and participating at my own pace, and communicating if an activity feels unsafe, or I feel it puts me at risk.
- Have fun, challenge myself and develop in my own way. Performing is optional.
I understand that many circus activities involve challenge and risk, including physical and emotional.

* Please note: Circus WOW activities are run as an arts skill rather than fitness, although there may be fitness aims and outcomes.

Disclaimer: I, THE PARTICIPANT, AGREE:
1. To accept full responsibility and personal liability for risk, participation and self care.
2. That Circus WOW, its management, trainers, employees, volunteers and associates are not liable for injuries and damages that may occur to my person or my personal belongings when participating in Circus WOW activities.
3. To refrain from consuming alcohol or other recreational substances prior to attending WOW classes, and/or attending WOW classes while still under the influences of said substances.
4. I agree to photos taken during classes or performances being used for Circus WOW promotional purposes such as on Facebook or circuswow.org.au
Signature*

Clear
Date*

MonthDayYear
Date

Medical Screening Questionnaire

AIM: to identify those individuals with a known disease, or signs or symptoms of disease, who may be at higher risk of an adverse event during physical activity/exercise.
I am blanks* years old.
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 had spells of dizziness 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 diagnoses muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?*
7. Have you spent time in hospital (including day admission) for any medical condition/ illness/ injury during the last 12 months?*
8. Are you currently taking a prescribed medication(s) for any medical condition(s)?*
9. Are you pregnant or have you given birth within the last 12 months?*
I am blanks* months pregnant or blank* months postnatal.
10. Do you have any other known condition(s) that may make it dangerous for you to participate in circus activities?*
- If you have answered YES to any of the above questions, please discuss with the training coordinator, or trainer, prior to class. You may be required to provide medical clearance from your GP or allied health professional prior to participating in WOW classes.
I believe that to the best of my knowledge, all of the information I have supplied within this form is correct.
Signature*

Clear
Date*

MonthDayYear
Date
Your Privacy

Circus WOW is committed to protecting your privacy. The information in thei form will only be disclosed to Circus WOW management and treated confidentially at all times.
Please verify that you are human*
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CIRCUS WOW CONSENT FORM & PRE-EXERCISE SCREENING FORM