ZUMBA® WITH REGGIE:

PHYSICAL ACTIVITY READINESS QUESTIONNAIRE

Your Details / Name
Telephone
Email
Allergies
Emergency Contact Details / Name
Relationship to You
Telephone
How did you find Zumba® with Reggie classes? / Zumba ® websiteOnline search (eg, Google)www.rhiles.zumba.comAdvertisement at venue (eg, banner, fliers)Poster or flier in local retail outlet/otherFlier through doorFacebookGumtreeOther online advertisementOther (please specify)
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For and in consideration of Raegan Hiles (hereinafter referred to as "Reggie"), permitting the participant to participate in the Zumba® Session. Participant, by signing below, hereby voluntarily indemnifies, releases Reggie from liability and holds Reggie harmless for any accident, injury, illness, death, loss, damage to person or property, or other consequences suffered by Participant or any other person arising or resulting directly or indirectly from Participant's participation in the Activity. In the event that Participant is injured, Participant agrees to assume any financial obligation, either through Participant's personal health insurance, or through some other means, for any medical costs which Participant incurs, Reggie assumes no responsibility for any medical expenses, injury, or damage suffered by Participant in connection with the use of any facilities or services in connection with the Activity.

IT IS THE INTENTION OF PARTICIPANT BY SIGNING BELOW TO EXPRESSLY ASSUME ALL RISK OF PERSONAL INJURY, DEATH, OR PROPERTY DAMAGE UPON HIM/HERSELF, TO THE EXCLUSION OFAND TO EXEMPT AND RELIEVE FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH.

Participant further agrees that Participant, his/her spouse, assignees, heirs, guardians, and legal representatives will not make any claim against, sue or attach for any loss or damage resulting from Participant's participation in the Activity.

Participant is aware of the potential dangers incidental to engaging in the activity, that this is a release of liability, a waiver of the participant's legal right to collect damages in the event of injury, death or property damage and a contract between participant and , and participant signs it of his/her own free will.

Participant's Signature:

Date: //2015

Terms and conditions: Participants must be over 16 years of age.

Data protection: We would like to keep you informed of future news, events or fundraising activities. If you would prefer not to receive information tick here ¨

This PAR-Q is designed to help you help yourself. Many health benefits are associated with regular exercise, and the completion of the PAR-Q is a sensible first step to take if you are planning to increase the amount of physical activity in your life.

For most people, physical activity should not pose a problem or hazard. The PAR-Q has been designed to identify the small number of people for whom physical activity might be inappropriate or those who should take medical advice concerning the type of activity most suitable for them. Common sense is your best guide for answering the questions below. Please read them carefully and select Yes/No opposite the question as it applies to you.

Yes / No
1 / Has your doctor ever said that you have a heart condition and recommended only medically supervised activity?
2 / Do you have chest pain brought on by physical activity
3 / Have you developed chest pain in the last month
4 / Do you tend to lose consciousness or fall over as a result of dizziness?
5 / Do you have a bone or joint problem that could be aggravated by the proposed physical activity?
6 / Has the doctor ever recommended medication for your blood pressure or a heart condition?
7 / Are you aware, through your own experience, or from a doctor's advice, of any other physical reason why you should not exercise without medical supervision?
8 / Are you currently, or have you been pregnant in the last six months?

If you ticked any of the "Yes" boxes above you must have your doctor's written consent before you participate and provide to Reggie prior to your participation in the class.

The instructor is NOT a medical specialist and therefore if you have any concerns about your health or participation in the classes, you should seek professional medical advice.

I confirm that if my circumstances change, I will keep Reggie informed of any changes in my health and provide a doctor's consent if applicable to participate in the classes.

I confirm that I participate at my own risk and as outlined overleaf too.

Name:

Signature:

Date: //2015

If you answered YES to any of the questions, please complete the next form return to . This will be forwarded to your GP; please then liaise with them to get it returned to us prior to your participation.