Health Screening and Informed Consent Form

All personal data will be stored securely for 7 years after your last class. We Require the data we collect to ensure the health and safety of clients and others whilst they are participating in our classes and for insurance purposes. If you have any questions please let us know. No personal information will be passed onto a third party unless required by law and contact details will not be used for marketing purposes.

If the student is under the age of 18 could a parent or gaurdian please complete the form from the perspective of the child.

Full name of student*

First NameLast Name

Birth Date*

DayMonthYear

Name of Parent/Gaurdian if required

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail*

Phone Number*

Area CodePhone Number

Emergency contact*

First NameLast Name

Phone number*

Area CodePhone Number

Common sense is your best guide when you answer this questionnaire. Please read the questions carefully and answer each one honestly: check YES or NO. If you answer yes to any of the questions, please give more details in the space provided.

Par-Q*

	Yes	No
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose balance because of dizziness or do you ever lose consciousness?
Do you have bone or joint problem (for example, back, knee, or hip) that could be worsen by a change in your physical activity?
Is your doctor currently prescribing drugs (for example water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?

Additional Information

Aerial Arts and Pole Dance are strenuous activities that can be quite challenging. By signing this form you are confirming that you are in good health and have no injury or illness that could be made worse by participating in a fitness activity. Please inform the instructor if, for any reason (such as illness or injury which might be aggravated by exercise), you should not participate in this activity.

Aerial Arts and pole dance are very high risk activities and although these sessions are designed to minimise the risk whilst still teaching you new skills, by taking part in classes you are accepting that Freestyle Fitness is not liable for any unexpected changes to your health resulting from you participating in these activities. Minor bruising and burns are likely to occur with this activity, hands may become sore and muscles may ache for a 3-7 days after participating in aerial arts.

Instructors reserve the right to determine the types of moves you will be taught and this will be based on the displayed ability and cooperation. PLEASE BE AWARE THAT NOT ALL STUDENTS WILL BE TAUGHT THE SAME MOVES.

All activities will be explained and demonstrated. You will be free to, and encouraged to ask questions should you wish.

If at any time, you feel undue pain or excessive discomfort then please STOP THE ACTIVITY and inform the instructor of your symptoms. You should be aware that you are FREE TO WITHDRAW FROM ANY ACTIVITY WITHOUT JUDGEMENT AT ANY TIME.

Some aerial arts and pole dance moves will require the instructor to spot you. This may require them placing hands on you to ensure your security on the apparatus. If you do not wish to be touched then you must inform the instructor at the start of each session and please be aware that refusing to be spotted may limit the moves you are permitted to try.

Freestyle Fitness withhold to the right to exclude any person from the academy if we consider the continuation of their participation a risk to themselves or other people.

I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction.

I consent to participating in Freestyle Fitness classes and I am aware of the risks involved. I have read the terms and conditions of participation and the session has been explained to me in full and the instructors have answered any questions I had about the sessions to satisfaction. I understand that I am free to withdraw from the activity at any time.

Signature*

Date

Health Screening Form

Member Information - Health questionnaire (Par-Q)

INFORMED CONSENT

Client informations - Signature