Creative Dance - 60 Plus Booking Form

60+ pilot

Please complete the following information which is required to help us ensure the coaches are aware of any issues which may affect participants. This registration form will only be kept for the duration of the activity and will then be destroyed (unless we are required under legal obligations to retain this).

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* 1. Contact Information

Name

Address

Postcode

Age

Email Address

Phone Number

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* 2. Emergency Contact Information

Emergency Contact Name

Emergency Contact Number

Alternative Emergency Contact

Alternative Emergency Number

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* 3. Consent for Photographs - for use on web-site, marketing, reports etc.

Yes

There are many health benefits associated with regular exercise and the completion of this PAR-Q is a sensible first step to take if you are planning to increase the amount of physical activity in your life. For most people being more active is very safe, however by answering the questions below this should help to give you an indication as to whether you should seek advice from a doctor before taking part.

Common sense is your best guide when answering these questions,

Please read carefully and tick YES or NO.

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* 4. Do you have any medical details / allergies etc we need to be aware of?

Yes

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* 5. Have you suffered from any recent injuries that may affect your participation?

Yes

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* 6. Has your doctor ever said you have heart trouble?

Yes

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* 7. Do you frequently have pains in your heart or chest?

Yes

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* 8. Do you often feel faint or have spells of severe dizziness?

Yes

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* 9. Has a doctor ever said your blood pressure was too high?

Yes

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* 10. Do you have a bone or joint problem(s) that may be worsened with exercise?

Yes

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* 11. Do you know of any reason why you should not take part in physical activity?

Yes

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* 12. Do you suffer from any problems of the lower back?

Yes

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* 13. Are you currently taking any medications?

Yes

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* 14. Do you currently have a disability?

Yes

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* 15. If you answered NO to all the questions above, it gives a general indication that you may participate in physical and aerobic fitness activities. Please note that this does not guarantee that you will have normal response from exercise and should you have any areas of concern these should be discussed with a medical professional.

If you answered YES to any of the above questions, please provide further details where appropriate discussing with your doctor before taking part in any further activity.

If you answered YES to any of the above questions, please provide further details here:

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* 16. Signed (Please type signature to indicate that you have read and understood the information above and are aware of the risks of taking part in physical activity):