• Anchor House, 24 Anchor Rd, Aldridge, Walsall, WS9 8PT
  • 07921 815301

Par-Q Form

Par-Q Form

Your Name

Gender

Date of Birth

Email Address

Phone Number

Class You're Interested In

Do you suffer from any of the following:
 Angina Back Problems Diabetes Epilepsy Joint Problems Asthma High Blood Pressure Chest Pains Dizzy Spells Fainting

Have you recently had an operation or illness?

Have you been pregnant within the last 6 months?

Are you taking any medication of which the instructor should be aware of?

Has your Doctor ever said that you have a heart condition?

Is there any other reason why you should not participate in physical activity?

Do you have any injuries or problems that might restrict your participation in an exercise programme?

If you have answered yes to any of the above, please give details:

Emergency Contact Name

Emergency Contact Number

What is your main reason for taking up an exercise programme?

If you answered "Other", please tell us why:

Disclaimer, Terms and Conditions

1. The trainers accept no responsibility for any loss, damage or injury to any participants / non-participants, or to the personal property of any participant / non-participant (or to any person accompanying whether by invitation or otherwise) who enters upon the trainer’s premises for whatever purpose and whether such loss, damage or injury is caused directly or indirectly by the Instructors.

2. Every participant in a daily class by their signature hereto warrants that to the best of their knowledge and belief they are suffering from no physical disability or illness whether or not such disability or illness is or may be affected by exercise of whatever degree, and further warrants to advise the Instructors if, after becoming a member they such suffer from such disability or illness and every applicant by their signature agrees to indemnify the Instructors class in respect of any disability or illness whether suffered in the class or otherwise.

3. By participating in a Phoenix Dance & Fitness class, every participant agrees to abide by our rules and regulations and understands the management reserves the right to refuse entry should these be contravened.

4. Rates for the Phoenix Dance & Fitness services are subject to change.

5. Phoenix Dance & Fitness respects your privacy. All personal details are treated as confidential and we will not share or redistribute your information with any third party.

Declaration

I confirm the information given above is accurate and I accept the above terms.

Signed:

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