Sonique Fitness PARQ and Liability Waiver and Health Questionnaire

Sonique Fitness ParQ and Liability Waiver

Fill out the form carefully for registration
Name*

First NameLast Name
Birth Date*

MonthDayYear
Email*
example@example.com
Mobile Number*

Area CodePhone Number
Home Number

Area CodePhone Number
Which classes are you interested in?

Clubbercise BarnsleyClubbercise DoncasterZumba DoncasterBeatbox BarnsleyTums Bums n GunsOnline Workouts
Emergency Contact Name*

First NameLast Name
Emergency Contact Number*

Area CodePhone Number

Medical History Please answer Yes or No to the following questions?*

	Yes	No
Have you ever suffered with Epilepsy? ( WARNING flashing lights are used in this class)
Are you pregnant? If yes, how many months?
Have you ever suffered from heart trouble?
Are you presently taking any form of medication?
Do you suffer from chest pains?
Do you ever have spells of dizziness or feel faint?
Have you ever had either high or low blood pressure, and/or high cholesterol?
Have you ever had asthma, chronic bronchitis or any other chest ailments?
Do you suffer from severe back pains or any other orthopaedic problems?
Do you suffer from severe headaches or migraines?
Are you recovering from a recent illness / operation or injury?
Have you any medical condition that we should be aware of?
Isthere any history of heart disease in your immediate family (before age 55)?

Please let us know if there is anything we need to be aware of before participation?
Use this space
PLEASE NOTE: If you have answered YES to any questions 1-13, you are advised to seek medical advice/approval before taking part in this class.

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 Clubbercise class and confirm that I am in appropriate
physical and mental condition to participate. If at any time I have questions, feel unsafe or unwell Iwill immediately inform the instructor (or their assistant) and discontinue further participation in the class.

I understand that neither the instructor or Sonique Fitness can be held responsible for any injuries or ill health of any kind arising from participation within this class.
Data Protection -This information will be stored in line with the General Data Protection Regulation (GDPR) and the Privacy Policy of the individual or company named at the top of this document.
IMPORTANT: If you don’t tick this box it willnot be possible to let you know about changes to classes, cancellations etc. You can unsubscribe at any time
Date of completion

MonthDayYear
Date
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Sonique Fitness ParQ and Liability Waiver