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sofunk® dance fitness
registration & health check
Physical Activity Readiness Questionnaire (PAR-Q)
*
Indicates required field
Name
*
First
Last
Phone Number
*
Email
*
Emergency Contact Name & Number
*
1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
*
Yes
No
2. Do you feel pain in your chest when you do physical activity
*
Yes
No
3. In the past month, have you had chest pain when you were not doing physical activity?
*
Yes
No
4. Do you lose your balance because of dizziness or do you ever lose consciousness?
*
Yes
No
5. Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in physical activity?
*
Yes
No
6. Is your doctor currently prescribing drugs (for example water pills) for your blood pressure or heart condition?
*
Yes
No
7. Do you know of any other reason why you should not do physical activity?
*
Yes
No
If you have answered:
'YES’
to one or more question:
You are required to gain consent from your doctor before participating in Sofunk®Dance Fitness
‘NO’
to all questions:
You acknowledge that you are taking responsibility for the accuracy of your replies and the decision that you are physically fit enough for unrestricted physical activity.
DECLARATION
I undertake that I have read, understood and correctly answered the questions set out above.
I wish to participate in Sofunk®Dance Fitness and I understand that my participation in this activity involves the risk of injury.
I confirm I am voluntarily engaging in a level of exercise that I consider acceptable and appropriate to my level of fitness.
If I have answered ‘YES’ to any of the questions above, by submitting this form I am also confirming that I have taken medical advice relating to my participation and my doctor has confirmed that I am fit enough to participate.
SUBMIT
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