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Online Par-Q Form

Waiver

Please read the waiver and accept it by following the directions below.

 

In consideration of being allowed to participate in the activities and programmes at Unique Fitness North East and to use the facilities and equipment owned and/or under the control of Unique Fitness North East, in addition to the payment of any fee or charge, I do hereby waiver, release and forever discharge Unique Fitness North East from any responsibility or liability for injuries or damages resulting from my participation in any activities or my use of equipment or facilities in the above mentioned activities.

I understand and I am aware strength, flexibility and aerobic exercise, including the use of equipment, both outside and inside, are potentially hazardous activities. I also understand that exercise and fitness activities involve a risk of injury and even death, and I am voluntarily participating in these activities and using equipment and facilities with the knowledge of the dangers involved. I hereby agree to expressly assume all and any risks of injury or death.

I do hereby declare myself physically able and suffering from no condition, impairment, disease or infirmity or other illness (other than those declared on the attached medical questionnaire) that would prevent my participation or use of equipment or facilities except as herein stated. I acknowledge that I have either had a physical examination and have been given my doctors permission to participate, or that I have decided to participate in activity and use of equipment and machinery without the approval of my doctor and do hereby assume all responsibility for my participation and activities, and utilisation of equipment and machinery in my activities.

I understand that during a training session, my trainer may have to use touch training to correct alignment and/or to focus my concentration on a particular muscle area to be targeted. If I feel uncomfortable or experience any type of discomfort with touch training, I will immediately request that my trainer discontinue using this technique.

I understand that Unique Fitness North East. may photograph and/or film their client events/sessions and I agree to allow them to use these pictures, films, and/or likenesses of me for promotional purposes. In the event I choose not to allow the use of the same for said purpose, I agree that I must inform Unique Fitness North East of this in writing.

I understand that the usage of any nutritional supplements is done under my own will.

In addition Unique Fitness North East cannot accept any responsibility for any valuables that may be lost, damaged or stolen whilst at Unique Fitness North East.

 

I have read the above waiver and, by signing below, I acknowledge that I understand and agree to all of the points raised within the waiver.

Tick the box to confirm you are signing the waiver and enter your name into the box.

 

Electronically signed   Signed by:

 

Contact Information

First Name (required)

Last Name (required)

Phone Number (required)

Address (required)

Gender (required)

Your Email (required)

Date Of Birth (required)
Day   Month   Year 

 

Emergency Contact

Emergency Contact Name (required)

Emergency Contact Telephone (required)

Relationship (required)

 

Questions

Has your doctor ever said that you have a heart condition and recommended only medically supervised physical activity?
YesNo

Have you had chest pain when you were or were not doing physical activity?
YesNo

Do you lose your balance due to dizziness or do you ever lose consciousness?
YesNo

Do you have high/low blood pressure?
YesNo

Do you suffer bone or joint problems?
YesNo

Have you been in hospital in the last 3 years?
YesNo

Are you currently on any medications/prescribed drugs?
YesNo

Are you pre/post natal?
YesNo

Do you suffer from breathing difficulties?
YesNo

Are you diabetic or epileptic?
YesNo

Do you have any allergies?
YesNo

Do you smoke?
YesNo

Do you have any medical problems not mentioned here that you believe may effect your ability to exercise?

YesNo

If you have answered 'yes' to one or more questions, could you please provide more details.

 
 

Please click the button below to submit your completed form. Please ensure that you have answered all of the questions.