PARQ

Thanks for Choosing Pre-Act!

The health, safety and well-being of all our clients and workshop participants are very important to us. So please take a few minutes to read and complete this questionnaire BEFORE joining the session. You can update this information at any time and feel free to Contact Us if you have any questions...

* Indicates required field

Name *

First

Last

Email *

Date of Birth (DD/MM/YYYY) *

Contact Number *

Workshop Date (DD/MM/YYYY) *

Company/Organisation *

ESSENTIAL HEALTH QUESTIONS

The following questions will tell you if you should check with a doctor before undertaking a change in physical activity patterns and taking part in our classes. If you are over 69 years of age and are not used to being very active, you should always check with your doctor first...

Do you have a heart condition or chest pain? *

YES NO

Do you suffer from high/low blood pressure *

YES NO

Do you suffer from dizziness, vertigo or loss of consciousness? *

YES NO

Do you have osteoporosis or osteoarthritis? *

YES NO

Do you suffer from significant back pain? *

YES NO

Do you have any significant bone, joint or muscle problems? *

YES NO

Do you suffer from a contagious medical condition? *

YES NO

Are you pregnant or have given birth within last six months? *

YES NO

Any other reason why you should not undertake physical activity? *

YES NO

If YES, then what? *

ADDITIONAL HEALTH QUESTIONS

Any serious allergies or sensitivities? *

Any conditions that require treatment during workshop? *

Any history of serious hospital admissions? *

Any learning difficulties or behavioural conditions? *

Any psychological, nervous or mental health issues? *

Any significant visual or hearing impairments? *

Do you require any health-related equipment during exercise? *

Anything else you think we should be aware of? *

EMERGENCY CONTACT DETAILS

Please provide us with the details of a suitable emergency contact in case we need to get in touch with someone whilst you're with us...

Emergency Contact Name *

Emergency Contact Number *

PHOTO/VIDEO CONSENT

We sometimes take photographs or video clips that may show your involvement in our workshops, to help promote Pre-Act services to other individuals or organisations...

Photo/Video Consent? *

I agree I do not agree

DECLARATION

I have answered all the questions above honestly and accurately. I have consulted a doctor if any of the essential health questions above were answered 'yes' and gained medical approval for me to undertake physical activity.

If there are any changes to medical conditions, emergency contact details or anything that could affect my participation, I will notify Pre-Act at the earliest opportunity. I consent to the personal data provided above to be shared with workshop trainers for the purpose of my safe participation.

I am aware of the physical nature of self-defence training and I understand that there may be some risk involved. I agree to waive any claim against Pre-Act and its representatives for any injury or illness arising from or during workshop participation. I understand that any medical treatment given will be first aid only.

Above all, I agree to participate in a safe and respectful manner.

I have read, understood and agree to the terms above *

<< Check here to electronically sign

Submit

Par-Q & Disclaimer

Thanks for Choosing Pre-Act!

ESSENTIAL HEALTH QUESTIONS

ADDITIONAL HEALTH QUESTIONS

EMERGENCY CONTACT DETAILS

PHOTO/VIDEO CONSENT

DECLARATION