PARQ Please complete the Physical Activity Readiness Questionnaire (PARQ) below. Your name Your email Town D.O.B. Mobile Where did you hear about Smur-FIT? Contact in case of a medical emergency only (this information will not be used for anything but the purpose stated) Name Relationship to you Telephone number Physical Activity Readiness Questionnaire (PARQ) If you are between the ages of 15 and 69, the PARQ will tell you if you should check with your doctor before you significantly change your physical activity patterns. If you are over 69 years of age and are not used to being very active, check with your doctor. Common sense is your best guide when answering these questions. Please read carefully and answer each one honestly: tick YES or NO. 1. Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor? YesNo 2. Do you feel pain in your chest when you do physical activity? YesNo 3. In the past month, have you had a chest pain when you were not doing physical activity? YesNo 4. Do you lose your balance because of dizziness or do you ever lose consciousness? YesNo 5. Do you have a bone or joint problem (for example, back, knee, or hip) that could be made worse by a change in your physical activity? YesNo 6. Is your doctor currently prescribing medication for your blood pressure or heart condition? YesNo 7. Do you know of any other reason why you should not do physical activity? YesNo If yes, please comment: YES to one or more questions: You should consult with your doctor to clarify that it is safe for you to become physically active at this current time and in your current state of health. NO to all questions: It is reasonably safe for you to participate in physical activity, gradually building up from your current ability level. A fitness appraisal can help determine your ability levels. Before submitting please read carefully: By completing and submitting this PARQ, you are confirming you have read and agreed the disclaimer. All completed questionnaires will be kept confidential and not shared with any third parties. You should always consult your physician or other healthcare provider before changing your diet or starting an exercise program. You understand that there is a risk of injury associated with participating in any exercise programme. You have answered all questions truthfully and to the best of your knowledge will inform the instructor of any change in your health. You as named person above, hereby assume full responsibility for any and all injuries, losses and damages that incur while attending, exercising or participating in any activities with Smur-FIT. Therefore you waive all claims against Smur-FIT, its instructors, or partners of individually or otherwise, for any and all injuries, claims or damages that might incur. I have read all of the above and I agree with these terms I confirm I have answered all of the above questions honestly and understand if I have not I could be at risk of injury, health complications or in extreme circumstances death could occur DATA PROTECTION AND CONSENT Sarah Fountain, Owner since September 2015 of Smur-fit is entirely responsible for the storage of your data supplied on this form once received via email to email@example.com. Smur-fit only receives information from you as an individual through this Physical Activity Readiness Questionnaire (PAR-Q) form. Smur-fit uses this information for insurance purposes, class attendance registers, historical trends and planning. Smur-fit could contact you through the email or mobile number you have supplied, to communicate events, newsletters, special offers, changes to the service provided and any other relevant information linked to Smur-fit. Your data will not be passed onto any third party. The data is stored for a period of 12 months on email which is exported to a secure spreadsheet via a secure device. After 12 months data is erased manually and a request for a new Physical Activity Readiness Questionnaire (PAR-Q) form will be sought. Should any of your information change in 12 months, it is your responsibility to update Smur-fit. By submitting this form you agree to the terms of the data usage and you give your consent to Smur-fit and Sarah Fountain, Owner of Smur-fit to contact you by any of the means of communication you have shared in the Physical Activity Readiness Questionnaire (PAR-Q). If you wish to not be contacted by Smur-fit via the details you have provided then please email firstname.lastname@example.org with Unsubscribe as the subject. From time to time Sarah Fountain may use your images that were taken during a session,on www.smurf-fit.co.uk and social media. If you wish to opt out of this at any time, please email directly on email@example.com.