PAR-Q - Zannatone

Full Name*

First NameLast Name

Telephone number*

HomeMobile

Email address

example@example.com

Full Name of emergency contact *

First NameLast Name

Telephone number of emergency contact *

HomeMobile

Please read the following questions carefully and check (X) next to the appropriate answers. Answer all questions honestly and to the best of your ability.

If you have answered 'Yes' to any of the above, please elaborate below:

Fitness Participation Agreement

I have answered the questions above to the best of my ability and affirm that my physical condition is good and I have no known conditions that would prevent me from participation. I acknowledge that participation is at my own pace and comfort level and that I may discontinue my participation in the sessions at any time. Furthermore, I agree to self-determine my exertion through good judgement and to discontinue any activity that exceeds my personal limitations. I understand that by signing this agreement that I hereby waive and release Zannatone, its staff, and all relevant employees in any way from liabilities or demands as a result of injury, loss, or adverse health conditions as a result of my participation. I confirm that I have read and understand this document and I wish to participate in fitness activities.

Photos and videos may be taken throughout the class for promotional purposes.

YES/ NO*

	Yes	No
Has your doctor ever said that you have a heart condition (had a stroke, heart attack, or heart surgery) and/ or that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Have you ever been told by a doctor that you have bone, joint, or muscle problems that could be made worse by physical activity?
Do you have a diagnosed illness that could be made worse by physical activity?
Is your doctor currently prescribing medication for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?
Are you pregnant now or have given birth within the last 6 months?
Have you had a recent surgery?
Are you currently on any medications, either prescription or non-prescription, on a regular basis?
Have you been diagnosed with type l diabetes?
Have you been diagnosed with type ll diabetes?
Do you suffer with arthritis or osteoporosis?
Do you suffer with epilepsy?
Do you suffer with asthma?

Please tick here if you do NOT want your photo taken.

Date

Signature of Participant:

Name

First NameLast Name