Leila Maria Dance Fitness Health waiver form
Leila Maria Dance Fitness consists of Zumba Gold, Zumba Fitness, Zumba toning & Clubbercise. Please take classes at your own pace and listen to your body at all times. Please stay well hydrated too, you can stop for a drink whenever you’d like to. Please note that Clubbercise is taught in a darkened room with flashing disco lights. If you suffer from any form of photosensitivity or light sensitivity this class unfortunately won’t be suitable for you.
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Your name
First Name
Last Name
Email
example@example.com
Your phone number :
Date of birth :
Emergency contact name:
Emergency contact number:
1. Have you ever suffered from epilepsy?
Yes
No
2. Are you pregnant? (If you are please consult a medical professional to check if these classes are suitable for you.)
Yes
No
If you’re pregnant, please select how many months. Or please select N/A
Please Select
1 month
2 months
3 months
4 months
5 months
6 months
7 months
8 months
9 months
N/A
3. Have you ever suffered from heart trouble?
Yes
No
4. Are you presently taking any form of medication?
Yes
No
5. Do you suffer from chest pains?
Yes
No
6. Do you ever have spells of dizziness or feel faint?
Yes
No
7. Have you ever had either high or low blood pressure and/or high cholesterol?
Yes
No
8. Have you ever had asthma, chronic bronchitis or any other chest ailments?
Yes
No
9. Do you suffer from severe back pains or any other orthopaedic problem?
Yes
No
10. Do you suffer from severe headaches or migraines?
Yes
No
11. Are you recovering from a recent illness/operation or injury?
Yes
No
12. Have you got any medical condition that we should be aware of?
Yes
No
13. Is there any history of heart disease in your immediate family (before age 55)
Yes
No
If you have any additional comments of anything you think I need to be aware of health wise that is relevant to you doing classes please could you type it here:
PLEASE NOTE: If you have answered YES to any of the questions 1-13 you are advised to seek medical advice/ approval before taking part in my classes.
I have been informed that if I answer YES to any of the questions in 1-13 I should seek medical advice/approval before commencing 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 confirm that I am in appropriate physical and mental condition to participate. If at any time I have questions, feel unsafe or unwell I will immediately inform the instructor or their helpers and discontinue further participation in the class. I understand that neither the instructor or Zumba Fitness LLC/ Clubbercise Ltd can be held responsible for any injuries or ill health of any kind arising from participation within these classes.
I agree to my personal contact information being used to send me important updates about class
I agree to my personal contact information being used to send me important updates about class AND other relevant updates
My signature below also acknowledges my agreement that the instructor or a helper may take short video clips of the class for social media (my Facebook business pages) and/or photos. These will not be focused on anyone’s dancing & it’ll just be a short clip around the room.
Thank you so much for completing this, I’m so grateful! If you have any questions please message me on 07710844854. Looking forward to seeing you in class :) Leila x
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