POLE ATTACK PARQ
Adult
Health Questionnaire
Personal Information
Date
*
Full Name
*
First Name
Last Name
Pronoun
Address
*
Street Address
Street Address Line 2
City
County
Post Code
E-mail
*
Mobile Phone Number
*
-
Area Code
Phone Number
MEDICAL INFORMATION
Have you had surgery in the last 6 months?
*
Yes
No
If stated yes, have you been cleared to return to exercise by your doctor?
*
Yes
No
N/A
Are you pregnant. (If stated yes, please contact us)
*
Yes
No
Have you had a baby in the last three months?
*
Yes
No
If stated yes, have you been cleared to return to exercise by your doctor or midwife?
*
Yes
No
N/A
Have you ever, or do you currently suffer from any of the following?
*
Epilepsy
Bone or Muscle Problems
Asthma/Respiratory Problems
Thyroid Problems
Heart Problems
Ligament or Tendon Problems
Dizziness/High or Low Blood Pressure
Blood Disorders
Circulatory Problems
Allergies
None of the above
If stated yes to any of the above, please explain. If you have stated, none of the above, please type N/A
*
If you suffer from Asthma, please ensure you always have your inhaler in class
*
Yes
N/A
If you suffer from any severe allergies that require immediate medication, you must always keep your medication with you at all times in class.
*
Yes
N/A
If you suffer from a severe allergies, please explain below?
*
Is there anything else you feel you should tell us regarding your current or previous health?
*
Are you currently taking any medicine that may affect your heath in class?
*
Yes
No
If stated yes, please explain in full?
*
Emergency Contacts
First Emergency Contact Name
*
First Emergency Contact Number
*
Second Emergency Contact Name
*
Second Emergency Contact Number
*
I understand that if I’m late for class and I miss the warm up, I will be refused entry into the class due to strict insurance regulations
*
Yes
I understand that when I am attending an open training session, I must do a thorough warm-up of the whole body lasting a minimum of 10 minutes. I will only carry out moves I am confident in and use a crash mat at all times. I will finish the session off with a cool down lasting a minimum of 5minutes. I fully understand I do not hold Pole Attack Ltd, Pole Attack Workshops Ltd or their associated instructors responsible for any injuries that maybe caused, when attending the open training sessions.
*
Yes
I agree to take full responsibility for my actions. Any injuries or incidents occurred during the class, are in no way the fault or the responsibility of Pole Attack Ltd, Pole Attack Workshops Ltd or their associated Instructor. I understand that it is my responsibility to take account of any physical impediments before I begin each class and I will notify the instructor of any changes to my personal, or medical information . I understand that I must not be under the influence of alcohol or drugs and if I feel unwell, I will cease participation straight away. If I find out I am pregnant. receive an injury, relocate or anything that stops me from attending am associated service, I will advise my instructor straight away. I understand that I will not be eligible for a refund or a transfer of course. I understand that due to the nature of the classes I am attending, physical spotting from a qualified instructor may required . I am the participant of the classes and I have read this form in its entirety. I have answered the questions accurately and to the best of my knowledge.
*
Yes
Signature
Thank you!!
Submit
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