Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Emergency Contact * First Name Last Name Emergency Contact * (###) ### #### Has your GP ever said that you have a bone or joint problems, such as arthritis that has been aggravated by exercise or might be made worse with exercise? * No Yes Has your doctor ever said that you have high or low blood pressure? * No Yes Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? * No Yes Have you ever felt pain in your chest when you do physical exercise? * No Yes Is your doctor currently prescribing you drugs or medication for a chronic condition? * No Yes Have you ever suffered from unusual shortness of breath at rest or with mild exertion? * No Yes Are you, or is there any possibility that you might be pregnant? * No Yes Do you know of any other reason why you should not participate in a physical activity program? * No Yes If you answered YES to any of the questions above please give details: If you answered YES to one or more questions: Please consult with your doctor before increasing your physical activity and/or taking a fitness appraisal. Tell your doctor what questions you answered 'yes' to on PAR-Q or present your PAR-Q copy. Tell your doctor what activities you are planning on participating in and follow the doctor’s advice accordingly. * Not Applicable Will seek further advice I, the undersigned, have read, and understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I agree that I am physically capable of participating in the sessions and accept complete responsibility for my own participation in the class. * Signed & Date: Thank you!
