PAR-Q Registration Form

Name*

First NameLast Name

Date Of Birth*

Date

Email*

example@example.com

Mobile phone number *

Area CodePhone Number

Are you able to receive text messages from the phone number above?

YesNo

Emergency Contact Information (Optional): In the event of a medical emergency, which friend or family member would you like us to contact?

Name Phone #

Has your doctor ever said that you have a bone or joint problem, such as arthritis, that has been aggravated by exercise or might be made worse with exercise?*

YesNo

Aqua Fitness - Wednesday 11-11:40amAqua Fitness - Wednesday 11:40-12:20pmAqua Therapy - Wednesday 12:20-1pmAqua Fitness - Friday 12:00-12:40pmAqua Therapy - Friday 12:40-1:20pm

Do you have high blood pressure?*

YesNo

Do you have low blood pressure?*

YesNo

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?*

YesNo

Have you ever felt pain in your chest when you do physical activity?*

YesNo

Have you ever suffered from unusual shortness of breath at rest or with mild exertion?*

YesNo

Do you often feel faint, have spells of sever dizziness or have lost consciousness?*

YesNo

Do you know of any reason why you should not participate in a program of physical activity?*

YesNo

Any additional information you would like the instructor to be aware of.

If you answered 'yes' to one or more questions:

If you have not recently done so, it is recommneded you consult with your doctor by telephone or in person before increasing your physical activity. Tell your doctor what questions you answered 'yes'' to on the PAR-Q or present your PAR-Q copy. After medical evaluation, seek advice from your doctor as to your suitability for:

- Unrestricted physical activity starting off easily and progressing gradually,

- Restricted or supervised activity to meet your specific needs, at least on an initial basis

No to all questions:

If you answered your PAR-Q accurately, you have reasonable assurance of your present suitability to take part in physical gym activity.

Assumption of risk:

I hereby state that I have read, understood and answered honestly the questions of the PAR-Q. I also state I wish to participate in activites that may include aerobic exercise, resistance training and stretching. I realise that my participation in these activites involves the risk of injury. Furthermore, I hereby confirm that I am voluntarily engaging in an acceptable level of exercise. I understand there is no Lifeguard on duty during my sessions and I take full resposibilty for my own safety and wellbeing.

Terms & conditions:

I understand that there will be no refunds for missed classes (efforts will be made to offer make-up classes, space permitting).

I hereby state I have read and agree to the terms & conditions stipulated by Peacehaven Aqua Fitness and Therapy.

Signature *

Date

Aqua Fitness & Therapy Class PAR-Q & Registration Form.