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Waiver for Pilates classes with Adam Walder

Thank you for completing our Physical Activity Readiness Questionnaire (PARQ). If you answer YES to one or more of the health and safety questions below, it is highly recommended you consult your doctor BEFORE you start becoming more physically active and before your first class. Tell your doctor about the PARQ and to which questions you answered YES, to ensure they see no reason why you should not take part in structured physical activity.

I Agree

In signing this form I confirm I have read, understood and fully completed the questionnaire below (please press Adult or Minor below to view full questionnaire). I confirm that my health and safety answers are true and accurate to the best of my knowledge and belief. I undertake to notify my trainer (Adam Walder) at once if any of my answers change. I take part in any recommended programme voluntarily, entirely at my own risk and waive any legal recourse to myself, or my property, arising from my participation. I agree to not use a piece of exercise equipment without first receiving sufficient guidance on the safe and effective use of the equipment. I am aware that physical activity can be hazardous and there is a risk involved. If I sustain or claim to sustain any injury while participating in the fitness programme in a class or at home in between classes, I acknowledge the venue and my trainer are not responsible.

I Agree

I understand the results of my training programme or coaching course cannot be guaranteed and may vary, my progress depends on my effort and cooperation in and outside of the sessions.

I Agree

First Participant's Name

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Health and safety questions
Has your doctor ever said that you have a heart condition or that you should limit your physical activity to that recommended by a doctor?*
No
Yes
Do you feel pain in your chest when you undertake physical activity?*
No
Yes
In the past month, have you had any chest pains when NOT undertaking physical activity?*
No
Yes
Do you lose your balance because of dizziness or do you ever lose consciousness?*
No
Yes
Is your doctor currently prescribing medication for blood pressure or a heart condition?*
No
Yes

If YES please state:
Do you have a bone or joint problem that could be made worse by a change in your physical activity?*
No
Yes

If YES please state:
Are you currently taking any medication of which the instructions we should be made aware?*
No
Yes

If YES please state:
Do you know of any other reason why you should NOT undertake physical activity?*
No
Yes

If YES please state:
Are you pregnant?*
No
Yes
Are you epileptic?*
No
Yes
Are you diabetic?*
No
Yes

Do you have any injuries? If YES please state:
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*

Last Name*

Relationship*
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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