Par-Q Form Share Facebook Twitter LinkedIn Google+ Email Par-Q Form Your Name Gender ---MaleFemale 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? ---YesNo Have you been pregnant within the last 6 months? ---YesNo Are you taking any medication of which the instructor should be aware of? ---YesNo Has your Doctor ever said that you have a heart condition? ---YesNo Is there any other reason why you should not participate in physical activity? ---YesNo Do you have any injuries or problems that might restrict your participation in an exercise programme? ---YesNo 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? ---Lose weightImprove general fitnessOther 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: By providing your email address you agree to being kept up to date with news at Phoenix Dance and Fitness. We will not share your details with any third party etc. If you don't want to receive this information then please let us know.