Physical Activity Readiness Questionnaire

KIMMYJFITNESS PARQ & LIABILITY WAIVER. ALL PARTICIPANTS MUST BE AGE 16 & OVER

Our community classes range from cardiovascular work, muscular strengthening, flexibility & stretch. We always start with a warmup & end with a cool down & stretch. If you suffer from any form of photosensitivity or light sensitivity epilepsy this class is not suitable for you as flashing lights are used to create atmosphere. Listen to your body, take the class at your own pace and choose lower impact options if you find the high impact moves too challenging. Stay hydrated during the class, drink whenever you need it & stop at any point you need to. Please note that photos and videos may be taken during the class for training and advertising purposes through our social media platforms.
Name*

First NameLast Name
Date of Birth *

MonthDayYear
Email*
example@example.com
Phone Number*

Area CodePhone Number
Emergency Contact Name *
Emergency Contact Number *

Area CodePhone Number
Are you a new or returning participant?
Where did you hear about us?
What is your reason for attending our sessions?

MEDICAL HISTORY ( please answer yes or no to the following questions) *

	Yes	No
1.Have you ever suffered with epilepsy? *WARNING: Flashing lights are used in this class*
2 Are you pregnant? (please note these classes are NOT suitable for pregnancy)
3. Have you ever suffered from heart trouble?
4. Are you presently taking any form of medication?
5. Do you suffer from chest pains?
6. Have you ever had either high or low blood pressure, and/or high cholesterol?
7. Have you ever had asthma, chronic bronchitis or any other chest ailments?
8. Do you suffer from severe back pains or any other orthopaedic problem?
9 Do you suffer from severe headaches or migraines?
10. Do you ever have spells of dizziness or feel faint?
11.Are you recovering from a recent illness / operation or injury?
12. Have you any medical condition that we should be aware of?
13.Is there any history of heart disease in your immediate family (before age 55)?

From the questions above please state anything that we need to be made aware of before participation
PLEASE NOTE: If you have answered YES to any questions 1 - 13, you are advised to seek medical advice/approval before taking part in our classes otherwise you are choosing to take part at your own risk....

*COVID-19* UPDATED MARCH 2022* - Though there are no longer any regulatons in place, it is advisory to follow government guidance should you have tested positive and or have any symptoms before attending a session.
Data Protection

All personal information that we collect from you will be used solely by us
KimmyJFitness for the purpose of keeping you informed on class information, updates and also keeping your health and emergency contact information up to date. This information will be kept and filed securely. We will never pass your information on to any third parties for any purpose other than legal obligation. This information will be stored in line with the General Data Protection Regulation (GDPR) and the Privacy Policy of KimmyJFitness. Pomsquad, Clubbercise & Fitness Pilates or any other brand will not receive this data and will not be responsible for protecting this data.
I agree to my personal contact information being used to send me important class updates and to keep all relevant health and contact information up to date.

I agree
I agree to my personal contact information being used to send me important class updates AND other relevant updates, news and offers

I agree
IMPORTANT: If you don’t tick this box it will not be possible to let you know about changes to classes, cancellations etc. You can unsubscribe at any time.

I have been informed that if I answer YES to any of the questions 1 – 13 above I should seek medical advice/approval before commencing this class. If I wish to continue without such advice I do so entirely at my own risk. I confirm that I have read, fully understood and answered each question honestly. I understand the nature of the classes from the information provided above and confirm that I am in appropriate physical and mental condition to participate. If at any time I have questions, feel unsafe or unwell I will immediately inform the instructor (or their assistant) and discontinue further participation in the class. I understand that neither the instructor, their assistant or any other organisations or brands can be held responsible for any injuries or ill health of any kind arising from participation within this class. I am also aware to all & any other terms & conditions stated above & also withing the privacy policies & cancellation policies in line with KimmyJFitness. By signing this I agree fully to all the terms & conditions listed above & within the policies of KimmyJFitness.

Please sign & click submit at the bottom for this page to complete the form.
Signature*

Clear
FULL NAME PRINTED IN CAPITALS *
DATE OF SIGNATURE *
Thank you for taking the time to complete this form! Should you have any questions please don't hesitate to contact your instructor at anytime. Please click submit below when completed. We look forward to seeing you at classes.
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KIMMYJFITNESS PARQ & LIABILITY WAIVER. ALL PARTICIPANTS MUST BE AGE 16 & OVER