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Integral Pre-Activity Questionnaire

The purpose of this form is to advise Integral of any increased risk of injury or illness you may experience as a result of participating in physical activity. Please complete this information carefully prior to commencing your first class.  If any of the below information should change, please advise Integral.

A parent or guardian must complete the pre-activity questionnaire for each child under the age of 18.

The information contained in this form is confidential and is subject to the laws and regulations contained in Australian privacy laws. 

You can see a copy of our Privacy Policy here: https://tinyurl.com/yxrzgph2 

Permission to participate in Integral program activities

I have voluntarily chosen to participate in fitness activities offered by Integral.  I have answered the questions below to the best of my ability and affirm that my physical condition is good and I have no known conditions that would prevent me from participation. I acknowledge that participation is at my own pace and comfort level, and that I may discontinue my participation at any time.

 Furthermore, I agree to self-determine my exertion through good judgement and to discontinue any activity that exceeds my personal limitations. I understand that by signing this agreement that I hereby waive and release Integral company, staff and all relevant employees in any way from liabilities or demands as a result of injury, loss, or adverse health conditions as a result of my participation. I affirm that I have read and understand this document and I wish to participate in fitness activities.

I give my permission to be photographed or videotaped within the context of class participation. I understand that I may ask any Integral team member to refrain from capturing my image, and that the image may be displayed in Integral publications, social media accounts, marketing or website.

I Agree

September 30, 2020

 

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Every so often we like to email our Integral students to keep them up to date on new timetables, special events, and news. By keeping this box checked, we'll include you when we send them out.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Medical Conditions, Medication and Injuries
Do you have or have you had:
Breathing problem (e.g. Asthma, emphysema)
Cystic fibrosis
Diabetes
Fainting/dizzy spells
Heart condition
Heat stroke/heat-related illness
High blood pressure
High cholesterol
Increased bleeding/haemophilia
Unexplained coughing during/after exercise
Do you take any medication?*
No
Yes

If 'yes', which medication?
Are you allergic to anything?*
No
Yes

If 'yes', what are you allergic to?
Do you have or have you had difficulty or problems with any of the following?
Balance/instability
Hearing
Motor sensory skills
Sleep apnoea
Speech/language
Vision
Do you have any of the following chronic illnesses or disabilities? Select all that apply.
ADHD
Cerebral palsy
Downs Syndrome
Hypermobility/EDS
Intellectual impairment
Obesity
Have you had surgery of any kind in the last 12 months?*
No
Yes

If 'yes', what type of surgery have you had and how long ago?
Are you/have you been pregnant or have you given birth in the last 24 months?*
No
Yes

If 'yes', please detail anything about the pregnancy or birth that you think we should know? Integral recommends that all pre- or post-natal women seek assessment by a women's health physiotherapist prior to participating.
Have you experienced any muscular/joint or bone pain while participating in physical exercise within the last 6 months?*
No
Yes

If 'yes', please explain any muscular/joint or bone pain, and any treatment by a medical professional.
Have you broken any bones or suffered injury to bones, joints or soft tissue within the last 6 months?*
No
Yes

If 'yes', please explain any breaks or injuries sustained, and any treatment by a medical professional.

If there are any other condition that we should know about, or reason that would prevent you from participating in activity with Integral, please detail below.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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