• Informed Consent

    By signing this document, I acknowledge that I have voluntarily chosen to participate in a program of progressive physical exercise, including Pilates and/or cardio dance fitness classes, known as Soka Movement (hereinafter referred to as “the Program”) which can enhance the musculoskeletal and cardio-respiratory systems. By signing this document, I acknowledge that I have been informed of the strenuous nature of the Program and the potential for unusual physiological results including, but not limited to, abnormal blood pressure, fainting, heart attack or death. By signing this document, I assume, to the extent legally permissible, all responsibility and risk for my health and wellbeing and hold harmless Kerry Ann Suteu, Rose Quartz Rising (also titled RQR), Soka Movement, and any of their associates and substitute instructors, including the studio wherein classes are held, from all damages or claims directly or indirectly resulting from my participation in the Program. I understand that the Program instructor welcomes and encourages questions about exercise procedures and the Program.

  • Waiver

    By signing this document, I acknowledge that I have been informed of the need to obtain a physician’s examination if I answer “yes” to any of the questions on the Physical Activity Readiness Questionnaire (PARQ) and will obtain written consent from my physician on the ParMedX form. I acknowledge the need to have a physician’s approval if I am pregnant at the time of participating in the Program. I fully understand that the Program will be strenuous and I choose to participate completely voluntarily. I assume, to the extent legally permissible, all responsibility and risk for my health and wellbeing and hold harmless Kerry Ann Suteu, Rose Quartz Rising, Soka Movement, and any of their associates and substitute instructors, including the studio wherein classes are held, from all damages or claims directly or indirectly resulting from my participation in the program, including damages or claims arising from the alleged negligence or fault of Kerry Ann Suteu, Rose Quartz Rising, Soka Movement, any substitute instructors, the studio wherein classes are held and any of their associates.

  • Social Media

    I am aware that photographs or videos may be taken at different times to assist in promoting the Program on social media and am aware of my rights to consent to the usage of such images.

  • Please select one:*

  • Physical Activity Readiness Questionnaire (PAR-Q)

    Please read each question below carefully and answer each one honestly: Yes or No

     

  • 1. Has your doctor ever said that you have a heart condition or high blood pressure?*
  • 2. Do you feel pain in your chest at rest, during your activities of daily living, OR when you do physical activity?*
  • 3. Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? (Please answer NO if your dizziness was associated with over-breathing including during vigorous exercise)*
  • 4. Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?*
  • 5. Are you currently taking prescribed medications for a chronic medical condition?*
  • 6. Do you currently have (or have had in the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active.*
  • 7. Has your doctor ever said that you should only do medically supervised physical activity?*

  • If you answered NO to all the questions above, you are cleared for physical activity.  Please sign the Participant Declaration. 

    If you answered YES to one or more of the questions above, you must have your physician complete the PAR-Med-X prior to participation in the program. 

  • Participant Declaration

    I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire.  I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that the community/fitness centre may retain a copy of this form for their records.  In these instances, it will maintain the confidentiality of the same, complying with applicable law.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Soka Movement w RQR

    Consent & Waiver
  • Should be Empty: