U4L PARQ & YOU FORM

Physical Activity Readiness Questionnaire

(PAR-Q & YOU)

For people aged 18-69 Years
Regular physical activity is fun and healthy and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active.
- If you are planning to become much more physically active than you are now, please start by answering the questions in the box below. If you are between the ages of 18 and 69, the PAR-Q will tell you if you should check with your doctor before you start.
- If you are over 69 years of age, and you are not used to being very active, check with your doctor they may have a GP Referral Programme available.
- Common sense is your best guide when you answer the questions below.
- Please read the questions carefully and check (tick) next to the appropriate YES or NO ... answering each question honestly and to the best of your ability.

HEALTH INFORMATION: YES/ NO*

Rows	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 have a diagnosed or recent injury that could be made worse by physical activity that you should only do when recommended by a doctor (bad back, sprained ankle or wrist) ?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you suffer from anxiety, stress, GAD, SAD?
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?
Do you know of any other reason why you should not do physical activity?
Are you new to Aerobics?
Have you attended an Aerobics class before?
Are you new to Yoga?
Have you attended a Yoga class before?

If you answered YES to one or more health questions:
- You should consult with your doctor to clarify that it is safe for you to become physically active at this current time and in your current state of health.
If you answered NO to ALL of the health questions:
- It is reasonably safe for you to participate in physical activity, gradually building up from your current ability level.
- A fitness appraisal can help determine your ability levels.
DELAY BECOMING MUCH MORE ACTIVE:

If you are not feeling well because of a temporary illness such as a cold, flu or a fever – wait until you feel better; or if you are or may be pregnant – talk to your doctor before you start becoming more active.
Personal Information

Data Protection Policies Apply. Your data will not be shared with any third parties
Full Name of Individual completing the form*

First NameLast NameGender: Male, Female, Non-Binary
Individual's Address *

Street Address

Street Address Line 2

Area (ie Easton)City

Post Code
Individual's Date of Birth*

DayMonthYear
Date
Email Address*
Mobile Number *
Emergency Contact Name*

First NameLast Name
Emergency Contact Email Address*
Emergency Contact Mobile/Landline Number *
Participant's Relationship to Emergency Contact (ie Partner, Spouse, Mother etc)*
Activity Class Participation Info

Uzima4Life offers general and private classes on the timetable ... to ensure you are attending the appropriate classes please complete the following:
Are you a member of the public from the local community (Individual)?Are you a member of staff in the private sector (Business)?Are you a member of staff in the public sector (Business/Schools) If YES please tick ?BCC Staff MemberBCC embRACE MemberBCC Education/Staff/TeacherNHS Staff/Medical TeamAre you a practitioner ie holistic health/therapist/etcOther
Class Timetable Information

Uzima4Life will be offering a selection of fitness activities designed to compliment and support your fitness journey. Is there an activity that you are interested in exploring?
Beginner to Improver Yoga ClassesImprover to Intermediate Yoga ClassesTriple Challenge (Step, Resistor Bands and Floorwork) Aerobic ClassesAnthemz Clubnite (A mixture of Dance, combat, Latin movements, neon lights, fun) Aerobic Classes (seasonal Oct-Feb)I prefer online MORNING CLASSES between 9.45-12 NOONI prefer online AFTERNOON CLASSES between 12-2PMI prefer ONLINE EARLY EVENING 4.15-5.15PM (May-Jul BCC+embRACE only)I prefer online EVENING CLASSES between 6-8PMI prefer a general ONLINE/POP UP YOGA IN THE PARK (WEATHER PERMITTING) WEDS BETWEEN 6-7.30PM (seasonal Jun-Sept)I prefer face-2-face classes but I'm happy to attend online classesI prefer PRIVATE ONLINE/FACE-2-FACE 1:1's please contact me to arrange a convenient timeI am a member of and will be returning to my local Gym/Studio after lockdownShould you wish to join Uzima4Life general classes please visit http://uzima4life.co.uk/shop-class-item-selections/4592868991
Fitness Participation Agreement

I {fullName17} have voluntarily chosen to participate in the Mindful, Vinyasa, Yoga, Chakra, Pop-Up, Aerobic, Classes or Workshops being offered by Uzima4Life. 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 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 Vinnett Alvaranga of Uzima4Life 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 offered.
Signature of Participant (iPad/phone):*

Clear
Type and confirm name of Participant*
Thank you for completing this Par-Q & You Form. Once your booking and Par-Q Form have been received, we will be in touch via email with confirmation of bookings, links, further information about our workshops and weekly practice sessions to come in 2021.

Should you have any other comments or questions, please let us know in the box below.

Looking forward to seeing you soon ~ Thankyou

Vinnett Alvaranga

Uzima4Life
Additional Notes or Comments ...

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Personal Information

Activity Class Participation Info

Class Timetable Information