THE POSITIVE MOVEMENT PROJECT CIC REGISTRATION, PAR-Q AND INFORMED CONSENT
COUCH TO 5K PROGRAMME/ WALK/RUN/TALK SESSIONS
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Post Code
Date of Birth
-
Month
-
Day
Year
Date
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
-
Area Code
Phone Number
Location
Crane Park- Walk/Run/Talk
Murray Park- Couch to 5K
PAR - Q (Physical Activity Readiness Questionnaire)
Moderate or vigorous exercise should not be a hazard for most people providing it is undertaken as part of a regular program starting from low intensity and progressing gradually. However, some people will need medical evaluation and advice before starting a program, some may need to exercise under medical supervision and some people may only be able to undertake restricted physical activity under medical supervision. If you answer NO to all the questions, it is reasonable for you to assume that you are in a suitable physical condition to start a regular graduated exercise program. If you answer YES to one or more question you are first advised to consult your doctor prior to participating in any exercise program.
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
*
Yes
No
Do you feel pain in your chest when you do physical activity?
*
Yes
No
In the past month, have you had chest pain when you were not doing physical activity?
*
Yes
No
Do you lose your balance because of dizziness or do you ever lose consciousness?
*
Yes
No
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
*
Yes
No
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
*
Yes
No
Do you know of any other reason why you should not do physical activity?
*
Yes
No
Signature
*
Informed Consent Document
I, the undersigned do hereby agree & acknowledge:
My consent to perform an exercise program led by The Positive Movement Project CIC
*
Agree
Disagree
I fully understand that there are potential risks associated with exercise, i.e. episodes of transient light-headedness, sprains, strains etc and I willfully assume these risks.
*
Agree
Disagree
My obligation to immediately inform the coach of any abnormal symptoms that I may suffer whilst exercising.
*
Agree
Disagree
That I have read, understood, and completed the medical screening questionnaire (PAR-Q) and obtained medical clearance if necessary.
*
Agree
Disagree
That I hereby release The Positive Movement Project CIC and their staff from any liability with respect to any damage or injury that I may suffer whilst exercising
*
Agree
Disagree
Signature
*
Data Collection
This programme has been funded by the Active Richmond Fund- all data collated will remain anonymous and allow the funders to identify how best to serve residents and where there may be a need for particular services in the community.
Are you a social housing tenant?
Yes
No
What is your occupation? If you are currently studying/ in further education please state this.
Which of the following best describes your household income (not including any benefits/financial support)
£0-£10,000
£10,001-£24,000
£24,001-£50,000
£50,001- £80,000
£80,000 +
Prefer Not To Say
How would you rate your current physical activity levels?
Excellent
Somewhat good
Average
Somewhat poor
Poor
Overall how would you rate your mental health?
Excellent
Somewhat good
Average
Somewhat poor
Poor
Submit
Should be Empty: