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Set Go Gym
Physical Activity Readiness Questionnaire (
PAR
-
Q
)
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Indicates required field
Have you been advised that you have a heart condition and should only do physical activity recommended by a doctor?
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Yes
No
Do you feel pain in your chest when you do physical activity?
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Yes
No
Do you ever feel faint, have spells of sever dizziness or have lost consciousness?
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Yes
No
Have you ever suffered from unusual shortness of breath at rest or with mild exertion?
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Yes
No
Do you have a bone or joint problem (for example, arthritis) that could be made worse by a change in your physical activity?
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Yes
No
Have you ever been told by a doctor that you have high or low blood pressure?
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Yes
No
Are you currently taking medication?
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Yes
No
Are you pregnant or have you had a baby in the last six months?
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Yes
No
Do you know of any other reason why you should not do physical activity?
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Yes
No
Set Go Gym Activity Waiver, Informed Consent/Assumption of Risk and Release of Liability
Consent/Assumption of Risk
I, the above named, agree to participate in one or more physical fitness programs/classes by Set Go Gym which may include, but not necessarily be limited to, weightlifting, aerobic activities or any other sporting or recreational endeavour by any affiliate, subsidiary or partner of Set Go Gym and/or Matthew & Amy Huntley (herein collectively referred to as Set Go Gym). Set Go Gym has made me fully aware that the fitness programs/classes which Set Go Gym offers and in which I desire to participate are of a nature and kind that are extremely strenuous and can/may push me to the limits of my physical abilities. I recognise and understand that the programs/classes are not without varying degrees of risk which may include, but are not limited to the following:
*Injury to the musculoskeletal and/or cardio respiratory systems which can result in serious injury or death.
*Injury or death due to negligence on the part of myself, my training partner, or other people around me.
*Injury or death due to improper use or failure of equipment.
*Injury or death due to a medical condition, whether known or unknown by me.
I willingly assume full responsibility for any and all risks that I am exposing myself to as a result of my participation in Set Go Gym programs/classes and accept full responsibility for any injury or death that may result from participation in any activity, class or physical fitness programs.
I hereby certify that I know of no medical problems or current injuries that would increase my risk of illness and injury as a result of participation in a fitness program designed by Set Go Gym. Set Go Gym informed me that there exists the possibility of adverse physical changes during an exercise program and I fully understand the same. Set Go Gym informed me that these changes could include abnormal blood pressure, fainting, disorder of heart rhythm, stroke, and in very rare instances, heart attack or even death, and I fully understand the same. With my full understanding of the above information, I agree to assume any and all risks associated with my participation in Set Go Gym fitness programs/classes.
Release of Liability
In full consideration of the above mentioned risks and hazards and in full consideration of the fact that I am willingly and voluntarily participating in the activities made available by Set Go Gym and with my full understanding of all of the above, I hereby waive, release and discharge Set Go Gym and its agents, officers, principals, employees and volunteers, of any and all liability, claims, demands, actions, rights of action, or damages of any kind related to, arising from, or in any way connected with, my participation in Set Go Gym fitness programs/classes, including those allegedly attributed to the negligent acts or omissions of the above mentioned parties. This agreement shall be binding upon me, my successors, representatives, heirs, executors, assigns, or transferees. If any portion of this agreement is held invalid, I agree that the remainder of the agreement shall remain in full legal force and effect.
If I am signing on behalf of a minor child, I also give full permission for any person connected with Set Go Gym to administer any first aid deemed necessary, and in case of serious illness or injury, I give permission to call for medical and or surgical care for the child and to transport the child to a medical facility deemed necessary for the well being of the child.
Use of picture(s)/film/likeness:
I agree to allow Set Go Gym, its agents, officers, principals, employees and volunteers the use of picture(s), film and/or likeness of me for advertising purposes. In the event I choose not to allow the use of the same for said purpose, I agree that I must inform Set Go Gym of this in writing.
I recognise that there is risk involved in the types of activities offered by Set Go Gym. Therefore I accept financial responsibility for any injury that I may cause either to myself or any other participant due to my negligence. I further agree to indemnify and hold harmless, to the maximum extent permitted by law, Set Go Gym their principals, agents, employees, and volunteers from liability for the injury or death of any person(s) and damage to property that may result from my negligent or intentional act or omission while participating in activities offered by Set Go Gym.
I have fully read and fully understand the foregoing assumption of risk, and release of liability and I understand that by signing it obligates me to indemnify the parties named for any liability for injury or death of any person and damage to property caused by my negligent or intentional act or omission. I understand that by signing this form I am waiving valuable legal rights.
I accept the terms above
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Yes
Name
*
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Last
Email
*
Phone Number
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