Physical Readiness Questionnaire

 

required fields

 

Child's name: *

 

Parent/guardian name: *Parent/guardian mobile contact number: *

 

Parent/guardian email address: *

 

Relationship to child: *

 

Child's date of birth: *

 

Child's current age: *

 

Prior to participating in classes you are required to complete this PAR-Q

together with an Informed Consent Release and Waiver Form (‘ICRW’) on behalf of your child. For most children, physical activity should not pose any problem or hazard, however, potential risks, whilst not apparent at rest, may be exacerbated by an increase in levels of physical activity. The PAR-Q is designed to identify those children for whom physical activity might be inappropriate or those who should seek medical advice concerning the type of activity most suitable for them. The ICRW contains information relating to the level of exercise your child is likely to be undertaking with us and should be read in conjunction with this PAR-Q.

Please complete the questionnaire below by reading each question carefully

and inserting a cross against the response that applies to your child. You are wholly responsible for your answers and if you are in any doubt you must seek medical advice.

Does your child have, or has he/she ever experienced any of the following?

If YES, please check all relevant boxes

High or low blood pressure?

 

Elevated blood cholesterol?

 

Diabetes or any other metabolic disease?

 

Chest pains either at rest or brought on by physical exertion?

 

Childhood epilepsy?

 

Regular headaches, dizziness or fainting?

 

Bone, joint or muscular problems with arthritis?

 

Asthma or other respiratory problems?

 

Any sustained injuries or illness?

 

Any allergies?

 

Is your child taking any medication?

 

Has your doctor ever advised your child to exercise?

 

Do you know of any other reason why your child should not participate in a

programme of physical activity?

 

Is there any further information you feel the instructor should be aware of,

for example family history of coronary heart disease etc?

D

If you answered 'yes' to one or more questions, please write full details here:

 

 

 

Any special dietary needs for your child? Please write full details here:

 

 

 

You acknowledge that you are taking responsibility for the accuracy of your replies and the decision that your child is physically fit enough for unrestricted physical activity with us.

By signing this PAR-Q, I the parent/guardian of the aforementioned child have read this form in its entirety and have answered the questions accurately and to the best of my knowledge. I understand that my child is responsible for monitoring themselves throughout any activity, and should any unusual symptoms occur, would cease participation and inform the instructor.

In the event that medical clearance must be obtained prior to my child’s participation in an exercise session, I agree to contact the GP and obtain written permission prior to the commencement of the exercise activity, and that this permission be given to PeteMooreFitness.

I understand that if my child fails to behave in a manner that is polite and social, he/she could be suspended from that activity or future activities.

 

Cancellation clause:

A minimum 24 hours’ notice must be given by both parties, you the client and ourselves, ahead of any cancellation of a pre-arranged session booking between both parties. Failure to do so on behalf of you, the client, waivers any return of pre-paid fees. Failure to do so on behalf of PeteMooreFitness will result in a free session for your child at a convenient date/time of a future session as agreed between both parties. This clause will be waived in the event of extreme or unavoidable circumstance resulting in late cancellation of a pre-arranged appointment, e.g. hospitalisation or travel

delays.

 

Date: *

Please also supply an alternative emergency contact name and mobile number

below.

Name: *

Relationship to child: *

Mobile contact number: *