Zumba with Kirsty PARQ

Name

First NameLast Name
Date of birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
WhatsApp number

Country codePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Has your doctor ever said you have a heart problem?
Have you ever had pain in your chest?
Do you often feel faint or have spells of dizziness?
Has a doctor said your blood pressure is too high?
Has a doctor said that you might have a joint / bone problem / arthritis that is aggravated by exercise
Have you been in hospital during the last 3 years?
Are you currently taking any medication?
Are you pre/post natal?
Do you suffer from asthma / breathing difficuties?
Do you suffer from diabetes / epilepsy?
Do you suffer from an allergy?
Is there a reason not mentioned here why you should not take part in physical activity with Zumba with Kirsty?
If you answer yes to any of the questions above, you should consult your doctor before commencing a physical activity program.

Please note the following

1) Please wear appropriate footwear when working out
3) Do not workout if you feel ill

WAIVER FORM

I hereby release and discharge Zumba with Kirsty and their staff of any claim, injuries, losses or liabilities suffered or incurred as a result of my paricipation in any fitness classes lead by Zumba with Kirsty
Signature
Today's Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Should be Empty: