Clone of Zumba Health Form

Zumba pre-exercise check form
Surname *
First Name *
Address *
City *
Postcode
Email *
Contact telephone number *
Emergency Contact Name
Emergency Contact Number
PARTICIPATION AUTHORISATION & RELEASE

The Zumba fitness program uses dance to challenge the systems of the body, especially the cardiovascular and skeletal systems. We advise that if you have any physical ailment, are taking medication or are otherwise not in excellent physical condition suitable for strenuous activity, your particapation may be injurious to you. The following questions are designed to alert you to the factors which may place you at risk from strenuous exercise. They do not include all physical risks. If you answer 'yes' to any question below you must consult your doctor before starting the Zumba fitness program - These questions are designed to help you. Please seriously consider whether any other problem, condition or medication suggess that you should seek medical advice before participating in the program
Has a doctor ever said you have heart trouble? *
Do you often feel faint or have dizzy spells/ *
Are you aged over 50 and NOT accustomed to physical exercise *
Have you had surgery in the past 3 months *
Do you have high blood pressure, cholesterol? *
Is your doctor currently prescribing drugs (.e.g water pills) for your blood pressure or heart condition? *
Has a doctor ever told you that you have a bone or joint problem such as arthritis that has been aggravated by exercise or might be made worse by exercise? *
Have you had chest pain in the past month when you were NOT doing physical activity? *
Are you now or have you been pregnant in the last 3 months? *
Do you have a cigarette smoking habit (or within the last year) *
Do you have a history of lung problems? *
Do you feel pain in your chest when you do physical activity? *
Is there any good physical reason not mentioned here why you should not follow an activity program? *
How did you hear about Zumba? *
In exchange for permission to participate in Zumba, I hereby grant the following release from Liability and Negligence. I release and hold harmless, Zumba, its officers, directors, employees, agents, landlords, lessees and sponsors from any and all liability for injury to my person or property caused in any manner, including negligence of the Released Parties, by my participation in the Zumba program. I acknowledge that the Zumba program is designed to stress the heart, lungs, cardiovascular and circulatory systems, muscles, joints, ligaments and tendons in an attempt to improve muscular strength and cardiovascular fitness. I acknowledge that I am aware I should warm up prior to engaging in Zumba and stretch upon completion of these activities. I acknowledge I have been advsed to consult wth my doctor with respect to any past or present injury, illness, cardiovascular problem, knee problem, joint problem or any other condition or medication that may affect my participation and ability to participate in and to endure the exercise program. I acknowledge that I have discussed with my doctor the appropriateness of the Zumba program in connection with any illness or condition that I now have or previously had and that I knowingly execute this release from liability and negligence.
By entering your name here and clicking the submit button, you agree to the above conditions *
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Zumba pre-exercise check form

PARTICIPATION AUTHORISATION & RELEASE