• Clubbercise with CYDNEE Class PAR-Q & Liability Waiver

    Please complete your personal details, medical history, liability agreement, contact preferences, and signature before participating in Clubbercise.

  • Class

  • Participant Details

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Medical History (PAR-Q)

  • Use Yes/No answers. Warning: Flashing lights are used in this class.
  • Have you ever suffered with epilepsy?*
  • Are you pregnant?*
  • 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 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 pain or any other orthopaedic problem?*
  • Do you suffer from severe headaches or migraines?*
  • Are you recovering from a recent illness, operation or injury?*
  • Have you any medical condition we should be aware of?*

  • Consent

  • Permission to Use Photos & Videos

    I grant Clubbercise Hull with CYDNEE the right to take photographs and videos of me and/or my child/children in connection with the above-identified subject. I authorise the person or organisation named above to copyright, use and publish the same in print and/or electronically for promotional purposes.I agree that they may use such photographs of with or without my name and/or my child/children’s names and for any lawful purpose.
  • I have read and understood the above.*
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Signature

  • Should be Empty: