Wellbeing Workshop Online Health and Waiver Form

Wellbeing Workshop Online Health Questionnaire and Waiver
Full name*

First NameLast Name
Date of Workshop

MonthDayYear
Date
Business or School Name
Health Information
Common sense is your best guide when you answer this questionnaire. Please read the questions carefully and answer each one honestly: check YES or NO.

Questions regarding your health*

Rows	Yes	No
Has your doctor ever said that you that you should only do physical activity recommended by a doctor?
Do you lose balance because of dizziness or do you ever lose consciousness?
Do you have bone or joint problem (for example, back, knee, or hip) that could be worsen by a change in your physical activity?
Do you know of any other reason why you should not do physical activity?
Are you pregnant?
Have you given birth to a baby within the past year?

If you answered yes to any of the above, please either tell me at the beginning of the session so that we can discuss, or if you'd rather message/talk to me privately please do. (For online sessions use the chat box in Zoom at the beginning of the session to send privately to me any details you want me to know).
Liability waiver
*** Please note, You must complete the online Health Questionnaire prior to the workshop. By completing the questionnaire you are acknowledging that you are choosing to do a Movement Workshop in your place of work or your own home (online) and you are assuming responsibility and liability for being aware of your surroundings and limitations (as well as screen sharing with others who have the ability to see you, if applicable). You absolve Movement Foundations (Emily Doe) of liability when using this service ***
Initials*

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Additional Information
Initials*

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Client Signature
Signature*

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Data Protection

In accordance with the General Data Protection Regulation of 25 May 2018, all data supplied to and held by Movement Foundations Limited, can be used by them to contact you and to administer their business operation. This information will be kept securely by Movement Foundations Limited and will NOT be shared with any third parties. You may request to see any data held about your school at any time by submitting a request to the Director Emily Doe. By submitting this form you agree that Movement Foundations Limited can email you about Online Classes and Company News.
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Wellbeing Workshop Online Health Questionnaire and Waiver

Health Information

Liability waiver

Additional Information

Client Signature