PARQ and informed consent

Pre-Activity Readiness Questionnaire (PAR-Q) and Informed Consent

For new and existing clients
Your Details
Full Legal Name *

First Name Last Name
Preferred Name and Pronouns *

Name Pronouns
Would you like your instructor to correct incorrect pronoun useage on your behalf? *
Yes/No
E-mail *
example@example.com
Date of Birth *

Day Month Year
Phone Number *
How did you hear about us? *
Friend/Facebook/Instagram etc
Please add me to the mailing list
Health Questions

Have you ever had any of the following:
Heart conditions or chest pain? *

YES NO
High or low blood pressure? *

YES NO
Faintness or dizzy spells? *

YES NO
Asthma? *

YES NO
Diabetes? *

YES NO
Are you pregnant or post natal? *

YES NO
Have you had any operations in the last year? *

YES NO
Any recent injuries? *

YES NO
Bone or joint problems? *

YES NO
Prescribed medicines or dietary supplements? *

YES NO
Any other medical conditions not previously mentioned? *

YES NO
If YES to any of the above please specify and also explain how this affects your ability to exercise or achieve your fitness goals?:
If you have answered yes to any of the above questions, we would recommend that you seek advice and confirmation from your doctor prior to participating in the class.
Do you know of any other factor which may affect your ability to participate in physical activity? *

YES NO
If YES please specify:
Lifestyle Questions
Describe your job (select whichever is relevant to you? *

Sedentary Active Physically demanding
Occupation

On a scale of 1-10 how would you rate your stress level? *

	1	2	3	4	5	6	7	8	9	10

1 is Very Low Stress, 10 is Very High Stress

Please describe your current activity levels (eg spin class x 2pw, gym x 3 pw, pilates etc)
What are your goals/aims of exercise?
If there is any other information you would like us to know please add it here
If you answered YES to one or more questions
Talk to your Doctor either in person or by phone before you start becoming more physically active and/or taking a fitness appraisal. Tell your Doctor what questions you answered yes to on this form.

You may still be able to do any activity you want as long as you start slowly and build up gradually or it may be that you need to restrict your activities to those which are safe for you.
Emergency Contact
Full Name *

First Name Last Name
Phone Number *
Relationship *

INFORMED CONSENT

Face to face training

The aims of all Devon Pole Dance classes are to improve cardiovascular fitness, muscular strength and endurance, flexibility, self-confidence, grace and style. The session will begin with a warm up, followed by a series of conditioning exercises or a recap of moves you have previously learned. We will then learn a new set of moves and tricks, finishing with a cool down, incorporating stretches to improve flexibility. Some weeks will incorporate choreography – or a routine.

Please notify the instructor before the session if you have sustained any injuries, illnesses or medical conditions or if you feel there are parts of the session you are unable to take part in – participation is completely voluntary.

All information given to the instructor is completely private and confidential under data protection legislation. Please ask as many questions as possible during the session, especially if you do not completely understand any move that is demonstrated.

As with all exercise, Devon Pole Dance classes carry an element of risk and you may experience some bruising or burn and feel slightly achy for a few days afterwards. This session has been designed to minimise those risks and with continued practice your body will become conditioned to the movements involved. If during the session you feel excessive pain or discomfort, please notify the instructor immediately.

Online classes

I agree to take full responsibility for my actions during any Devon Pole Dance online class.
Any injuries or incidents occurred during the classes are in no way the fault or the responsibility of Devon Pole Dance or the Instructor.
I understand that it is my responsibility to take account of any physical or mental impediments I have before I begin any Devon Pole Dance classes. I have notified the instructor of any medical conditions that may affect me during the class.

I accept that I am responsible for providing all of my own equipment including but not limited to the pole (which must be purchased from a professional manufacturer and installed as per the manufacturer guidelines), safety mat, clothing and footwear and the instructor will not accept any liability arising out of defective equipment. I acknowledge that the instructor is not present with me and cannot make an adequate assessment of the area where I am exercising and it is my responsibility to ensure the area is clear, safe and free from any hazards which may cause injury to me or to others.

Sign below to confirm that you understand the differences between face to face training and online training described above and that you understand you are able to withdraw from the session(s) at any time.
Name *

First Name Last Name
Signature *

Clear
TERMS AND CONDITIONS

Should you need to cancel your class for whatever reason prior to its commencement, please see below for our cancellation policy:
1. To ensure that nobody is disappointed, could you please provide a minimum of 24 hours’ notice for any class cancellations. Thank you. Classes that are cancelled inside of the notice period will be charged for. Any cancellations outside of the notice period will be refunded. (Extenuating circumstances may be accepted at the discretion of the instructor). Some classes/workshops cancellation policy may differ – please check with your instructor.
2. Devon Pole Dance reserves the right to cancel a course/class at any time. A refund or alternative class will be offered for any classes missed.
3. Devon Pole Dance reserves the right to cancel your place on your class/workshop if payment is not received.
4. I understand that it is my responsibility to inform Devon Pole Dance of any changes to my health including any new medical conditions or injuries that may affect my capacity to participate.
5. I will not hold Devon Pole Dance liable in any way for injuries that occur during training.
6. Students are required to notify Devon Pole Dance if they are teaching or assisting at any other local aerial fitness school.
7. All material taught in Devon Pole Dance classes is not to be taught in any form at any other location without prior approval of Devon Pole Dance.
8. For studio classes, all students are required to abide by both the Safety Rules and General Class Policies.
9. Your details will be used solely for the purposes of Devon Pole Dance and will not be shared with any outside agency.
10. To ensure the safety of all class members, the following rules are to be followed at all times:
a.       The instructor must be informed of any injury you have sustained that could affect your ability to participate in the class

b.       All directions from the instructor are to be followed at all times.

c.        Do not attempt any move or trick that you are unable to complete without assistance or have not been taught explicitly by the instructor.

d.       Do not attempt to teach any other students in your class/group.

e.       Any concerns over equipment should be reported to the instructor immediately.

f.        You are advised not to apply any moisturisers, oils or lotions on the day of your class. Doing so will be at your own risk.

g.       You are advised to wear appropriate clothing and footwear for the class you are participating in.

h.       Jewellery is to be removed before the class

Sign below to confirm that you have read, understood and agree to all the conditions listed above.
Name *

First Name Last Name
Signature *

Clear
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Pre-Activity Readiness Questionnaire (PAR-Q) and Informed Consent

Health Questions

Lifestyle Questions

If you answered YES to one or more questions

Emergency Contact

INFORMED CONSENT

TERMS AND CONDITIONS