Name *

First Name

Last Name

Date *

MM

DD

YYYY

Phone *

(###)

###

####

Gender *

Male

Female

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *

Yes

No

2. Do you feel pain in your chest when you do physical activity? *

Yes

No

3. In the past month, have you had chest pain when you were not doing physical activity? *

Yes

No

4. Do you lose your balance because of dizziness or do you ever lose consciousness? *

Yes

No

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? *

Yes

No

6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? *

Yes

No

7. Do you know of any other reason why you should not do physical activity? *

Yes

No

If you answered YES to one or more questions: Talk with your doctor by phone or in person BEFORE you start becoming much more physically active or BEFORE you have a fitness appraisal. Tell your doctor about the PAR-Q and which questions you answered YES. You may be able to do any activity you want — as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those which are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice. Find out which community programs are safe and helpful for you. If you answered NO to all questions: If you answered NO honestly to all PAR-Q questions, you can be reasonably sure that you can start becoming much more physically active – begin slowly and build up gradually. This is the safest and easiest way to go. Take part in a fitness appraisal – this is an excellent way to determine your basic fitness so that you can plan the best way for you to live actively. It is also highly recommended that you have your blood pressure evaluated. If your reading is over 144/94, talk with your doctor before you start becoming much more physically active. *

I confirm I have read and understood the above

Waiver and Release of Liability *

I/We hereby understand and acknowledge that the services, training, programs and events held by The Body Engineers Inc. may expose me to many inherent risks, including accidents, injury, and/or illness. I/We assume all risk of injuries associated with participation including, but not limited to, falls, contact with other participants, and all other such risks being known and appreciated by me. I/We hereby acknowledge my responsibility in communicating any physical and psychological concerns that might conflict with participation in activity. I/We acknowledge that I am physically fit and mentally capable of performing the physical activity I chose to participate in. After having read this waiver and knowing these facts, and in consideration of acceptance of my participation and The Body Engineers Inc. furnishing services to me, I agree, for myself and anyone entitles to act on my behalf, to HOLD HARMLESS, WAIVE AND RELEASE The Body Engineers Inc., its officers, agents employees, organizers, representatives, and successors from any responsibility, liabilities, demands, or claims of any kind arising out of my participation in The Body Engineers Inc. services, training, programs, and/or events. By my signature I/We indicate that I/We have read and understand this Waiver of Liability. I am aware that this is a waiver and a release of liability and I voluntarily agree to its terms.

I confirm and accept the Waiver and Release