Registration & Agreement

PAR-Q: Physical Activity Readiness Questionnaire

Name *

First

Last

Email Address *

Contact Number *

Emergency Contact name and number (only required for classes in person)

1. Do you have High or Low blood pressure? *

Yes - High blood pressure Yes - Low blood pressure No

2. Has your doctor ever said that you have a bone/joint problem, such as arthritis, that might be, aggravated by exercise? *

Yes No

3. Do you have Diabetes or any other metabolic disease? *

Yes No

4. Has your doctor ever said that you have raised cholesterol? *

Yes No

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

Yes No

6. Have you ever felt pain in your chest when you do physical exercise? *

Yes No

7. Have you ever suffered from shortness of breath at rest or with mild exertion? *

Yes No

8. Is there any history of Coronary Heart Disease in your family? *

Yes No

9. Do you frequently feel faint, or have spells of dizziness or lost consciousness? *

Yes No

10. Are you, or is there any possibility that you might be, pregnant? *

Yes No N/A If you have had a baby recently please consider postnatal yoga classes and ensure you have consulted your doctor on your suitability for physical activity.

11. If you answered ’Yes’ to one or more questions, please consult your doctor if you have not already done so. Ask your doctor’s advice on your suitability for physical activity. Please give details you feel are relevant in the box below.

12. Declaration (if you answered yes to one or more of the questions): I have taken medical advice and declare I have been cleared by my doctor (GP, specialist or other qualified health professional) to take part in exercise. *

Yes No N/A

13. For classes delivered online via Zoom, you agree to take full responsibility for your personal health and wellbeing or that of your dependents for the full duration of the session by submitting this form . *

Agree During your practice please listen to your body and feel comfortable in a yoga pose. If at any point a pose feels uncomfortable or painful then can stop and take a resting Yoga pose at any time during the session.

14. Informed Consent / Agreement *

I understand that yoga includes physical movements as well as an opportunity for relaxation, stress re-education and relief of muscular tension. As is the case with any physical activity, the risk of injury or serious disabling is always present and cannot be entirely eliminated. Yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. I affirm that I alone am responsible to decide whether I or my child are fit to practice yoga. I hereby agree to irrevocably release and waive any claims that I and/or my child/children, now or hereafter, may have against (Deepa Chahal at Yoga Challo). I hereby state that I have read and understood the questions / information above. I also state that I wish to participate in activities, which may include aerobic exercise, resistance exercise and stretching. Furthermore, I hereby confirm that I am voluntarily engaging in exercise.

15. By submitting this form, you give permission to receive emails. This will keep you informed on current services available. This is following General Data Protection Regulations (GDPR) 25th May 2018. *

Agree

Signature: *

Date: *