Fit n Footloose PAR-Q

Bundilla Bootcamp Welcome Sheet

Client Information
Full name

First NameLast Name
Male or Female

Other
Date of birth

DayMonthYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: 0000-000-000.
E-mail
example@example.com
Next of Kin (NOK)

First NameLast Name
NOK Phone Number
Emergency Contact Format: 0000-000-000.
Permission to post on our Social Media
Client information - Health questionnaire (Par-Q)

Physical Activity Readiness Questionnaire
Please read the questions carefully and answer each one honestly:YES, NO or N/A

Par-Q

Rows	Yes	No	N/A
1. Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?
2. Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?
3. Do you ever feel faint, dizzy or lose balance during physical activity/exercise?
4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?
5. If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months?
6. Do you have any other conditions that may require special consideration for you to exercise?

IF YOU ANSWERED ‘YES’ to any of the 6 questions, please seek guidance from an appropriate allied health professional or medical practitioner prior to undertaking exercise.
I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction.
Initials

Risk Factors - your answers to these questions are recommended as they will help determine appropriate exercise prescription based on established risk factors.

Rows	Yes	No	N/A
7. Do you have a family history of heart disease (e.g. stroke, heart attack)?
8. Do you smoke cigarettes on a daily or weekly basis or have you quit smoking in the last 6 months?
9. Have you been told that you have high blood pressure?
10. Have you been told that you have high cholesterol/ blood lipids?
11. Have you been told that you have high blood sugar (glucose)?
12. Are you currently taking prescribed medication(s) for any condition(s)?
13. Have you spent time in hospital (including day admission) for any condition/illness/injury during the last 12 months?
14. Are you pregnant or have you given birth within the last 12 months?
15. Do you have any diagnosed muscle, bone, tendon, ligament or joint problems that you have been told could be made worse by participating in exercise?

If you answered yes to any of the above, please give details below.
Waiver and Release of Liability
1. I am voluntarily participating in training programs, exercises and events both face to face and online, provided by Karren Ross and Louise de Bomfort-Scott during which I will receive instruction.

2. I am aware that there are potential risks of injury when exercising, and although all the trainers at Bundilla Bootcamp are fully qualified and will do everything in their power to minimise the chance of injury, they are not able to completely remove this risk and there is, therefore, a chance that an injury may occur while exercising.

3. I assume full responsibility for any risks, injuries or damages known or unknown which occur as a result of participating in any activity and I, therefore, waive all claims against Karren Ross and Louise de Bomford-Scott for personal injury.

4. I understand that it is my responsibility to consult with a physician prior to and regarding any Fitness Program. I represent and warrant that I am physically fit and have no medical condition that would prevent my full participation.

5. I have read and understood all details of the Waiver and Release of Liability above and fully understand its contents. I voluntarily agree to the Terms and Conditions stated above.
Client information - Signature
Signature
Date

DayMonthYear
Date
Should be Empty:

Bundilla Bootcamp Welcome Sheet

Client information - Health questionnaire (Par-Q)

Waiver and Release of Liability

Client information - Signature