ONLINE CLASS PAR-Q PERSONAL DETAILS Please answer all questions below. Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country DOB * Email * Mobile * Mailing list * Would you like to join my mailing list for exclusive offers and news? Yes No How would you rate your activity level (this is all the activity you may do during the week such as walking, gardening etc., as opposed to formal exercise such as running or going to a class ( 1 - Inactive to 10 - Very active)? * 1 - Inactive 2 3 4 5 6 7 8 9 10 - Very active Has your doctor ever said that you have a heart condition and recommended only medically supervised activity? * Yes No Do you have chest pain brought on by physical activity? * Yes No Have you developed chest pain in the last month? * Yes No Do you suffer from dizziness or loss of consciousness? * Yes No Do you have a bone or joint problem that could be aggravated by the proposed physical activity? * Yes No Are you currently, or have you been pregnant or given birth in the last 6 months? * Yes No Have you had an operation in the last 6 weeks? * Yes No Are you on any medication (please state below)? Do you have any other medical conditions/injuries/strains? Please state below. Are you aware, through your own experience or from a doctor's advice, of any other physical reason, why you should not exercise without medical supervision? * Yes No If you have answered NO honestly to all questions above, you can be reasonably sure you are safe to exercise. If you have answered YES to one or more of the questions, talk to your personal trainer and ensure they are aware of these. Your personal trainer may restrict or modify your physical involvement in an exercise or activity. Depending on the severity of these positive answers, your personal trainer may ask you to refrain from an activity altogether before seeking medical advice. If this is the case you will be required to tell your GP or other relevant practitioner about the questions to which you answered positively, then approval to exercise will need to be obtained before full physical commencement of your sessions. Note any concerns below. If you have answered YES to any of the questions above, I confirm that I have sought advice from a medical professional who has approved me to exercise. Yes No I confirm that all information given is accurate to the best of my knowledge and that all exercise is done at my own risk throughout the duration of my personal training sessions. I confirm that I will advise CLC Fitness immediately upon becoming aware of any new medical conditions or should any circumstance arise whereby I would answer positively to any of the statements above. * Electronic signature of participant (or parent/guardian if client is aged under 18) Informed Consent for Exercise Prescription Please confirm that you understand the inherent risks of participating in HIIT classes. Potential risks * HIIT and Strength classes are designed to place a gradually increasing workload on the cardiovascular and musculoskeletal systems and thereby improve their function and your fitness. Whilst our priority is to provide a safe and effective class and to minimise any risk of injury, not all exercises will be suitable for everyone. As a result, there is an inherent risk in participation. If you feel any pain or discomfort at any time, stop doing the activity concerned and inform the instructor. If you have any reason which you believe means you should not perform any of the activities in the class, do not perform that activity and inform the instructor of your decision and the reasons. By selecting "I understand" below, you are confirming that you have read and understood this statement, are providing an informed consent to exercise and agree that you are participating at your own risk. If the participant is aged under 18, then this consent must be given by a parent or guardian of the participant, who must give their electronic signature in the box below. I understand Consent * This exercise programme has been explained to me and my questions regarding the programme have been answered to my satisfaction. I understand that I am free to withdraw at any time. The information obtained will be treated as private and confidential. Where the participant is aged under 18, this consent must be given by a parent or guardian, who must give their electronic signature in the box below. I understand Electronic signature of participant (or parent/guardian if participant is aged under 18) * Date * MM DD YYYY Thank you!
