PAR-Q & LIABILITY WAIVER
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- Jennifer Manning
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1 PAR-Q & LIABILITY WAIVER Full name: Address: Post code: Mobile: Home phone: address: Date of Birth: Occupation: Emergency contact name: Relationship to you: Emergency contact phone number: Tara Blackaby runs a variety of all-over body workouts through my business Tara s Fitness Fusion including personal training, bootcamp fitness, high intensity interval training (HIIT), aerobic and weights-based classes as well as toning and sculpting classes such as pilates and fitness pilates. I strongly recommend that before you undertake any activity on any premises, that you should first undergo a wideranging and complete physical examination from a registered medical practitioner, to ensure that you are fit and able to commence your exercise program. You should advise your medical practitioner that the exercise program includes weightlifting, circuit training, aerobic and anaerobic exercise over prolonged periods of time. Please make me aware of ANY injuries or illnesses you may have BEFORE the start of a class so that I can advise you adapt the class/exercises as necessary. It may be that you will be advised NOT to take part in the class or that I require written consent by a doctor that you are fit and healthy enough to take part in the classes that you wish to book on to. This is purely for your own health and should be taken as such. So that you enjoy the class and get the most from it; listen to your body, take the classes at your own pace and choose lower impact options if you find the high impact moves too challenging. It is vital you stay hydrated during the class, have a drink whenever you need it. Above all, have fun and let me know about anything that is causing you concern. To ensure we get off to a great start, please answer the following questions carefully and honestly:
2 MEDICAL HISTORY (please circle your answers) 1. Are you pregnant? If yes, how many months?... YES / NO 2. Are you presently taking any form of medication? YES / NO 3. Have you ever had asthma, chronic bronchitis or any other chest ailments? YES / NO 4. Do you suffer from any orthopedic problem? YES / NO 5. Are you recovering from a recent illness / operation or injury? YES / NO 6. Have you any medical condition that we should be aware of? YES / NO 7. Is there any history of heart disease in your immediate family (before age 55)? YES / NO PLEASE NOTE: If you have answered YES to any questions 1-7, you are advised to seek medical advice/approval before taking part in this class. Please circle if any of the following medical conditions are relevant to you, either in the past or currently. Please add further detail below to explain any that you circle. Dizziness Fainting Stroke Diabetes Arthritis Epilepsy Glandular fever Heart attack Asthma Chronic fatigue Panic attacks Kidney ailments Heart condition Sleeping disorders High Cholesterol Bone abnormalities Circulation problems Back pain Blood clots Pains in chest Headaches or migraines Heart murmur Low Blood Pressure High Blood Pressure Anxiety or depression Mental abnormalities MS Inflammation Allergies (please specify Infectious disease Details of the above:
3 1. Do you have any current or pre-existing injuries that may restrict you in any way? If yes, please give details: 2. Are you currently taking prescribed medication? If yes, please give details: 3. Have you been hospitalised in the past 12 months? If yes, please give details: 4. Do you have any joint injuries? If yes, please give details: 5. Do you have soft tissue injuries (strains, tears, etc)? If yes, please give details: 6. Are there any other conditions you have, which may affect your activity program? If yes, please give details: 7. Have you been pregnant in the last 12 months? 8. Have you had any major operations in the last 2 years? If so, please give details: 9. Please give details outlining your exercise history: activities, time frame, problems etc. 10. In some classes I provide resistant bands and balls (elastic/plastic based) do you have any allergies affecting the use of these items?
4 Declaration: I have been informed that if I answer YES to any of these questions I should seek medical advice/approval before commencing the 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 honestly. I understand the nature of the classes and confirm that I am in proper physical and mental condition to participate. If at any time I have questions, feel unsafe or unwell I will immediately inform the Instructor and discontinue further participation in the class. I understand that the Instructor cannot be held responsible for any injuries or ill health of any kind arising from participation within the sessions or classes. I understand that I will be using a variety of indoor and outdoor equipment and do so at my own risk. PRIVACY STATEMENT AND ACKNOWLEDGMENT Please note: In this privacy statement and acknowledgment you acknowledge that you will in completing this acknowledgment, disclose to me, Tara Blackaby (of Tara s Fitness Fusion) information about you including information in relation to your health. We agree that in dealing with this information, we will deal with that information in accordance with the privacy principles set out below and with GDPR legislation (further details are available within my privacy policy on my website TERMS AND CONDITIONS AND PRIVACY POLICY By signing this document, I acknowledge that engaging in physical activity may lead to serious or disabling injury, even death. I understand that all activities in any exercise program are optional, and I may stop at any time. I RELEASE my Instructor from any liability for any injury which I may suffer whilst participating in any activities howsoever otherwise caused. I have been advised and warned to obtain a wide-ranging and complete physical examination by a registered medical practitioner to confirm that I am fit and able to engage in all of the activities within this class including a variety of indoor and outdoor equipment. I acknowledge that I have either had a physical examination and have been given my doctors permission to participate, or that I have decided to participate in activity and use of equipment and machinery without the approval of my doctor and do hereby assume all responsibility for my participation and activities, and utilisation of equipment and machinery in my activities; therefore, I do so at my own risk. Where the applicant is a minor, this application and agreement must be signed by the minor and his or her guardian, who warrants and agrees by signing this agreement that he or she is authorized to enter into this agreement on behalf of the minor and remains responsible for the minor of all the terms and conditions set out herein, and indemnifies, the personal trainer from any claim by the minor. I acknowledge that I have read and understood all of the terms and conditions of this agreement prior to me signing the agreement and that the information it contains is true and correct.
5 Photographic Consent We sometimes take photographs and /or videos during the classes for use on social media but will not use images of you without your prior permission. Please tick ONE of these options: I am happy for photographs/videos to be taken of me during classes and used in national and local publicity, communications, publications and digital channels (e.g. website, social media) I do not wish any photographs/videos to be taken of me during classes. All personal information that we collect from you will be used solely by Tara Blackaby trading as Tara s Fitness Fusion and will be kept and filed securely in accordance with GDPR legislation (full details within our privacy policy available on my website Your personal data will be used primarily to notify you and keep you informed of any updates, news and any important changes that may affect you. Providing me with your personal contact information is not mandatory, however without your contact information I will not be able to notify you in advance of any important changes such as class cancellations and price changes. I do not send out marketing s, but if in the future I wish to promote classes or offers to you I will ask for your consent first. Signed:...Date:... I do NOT consent to my personal data being saved and used to notify me and keep me informed of any updates, news and any important changes that may affect me.
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