“Annexure A” Physical Fitness Questionnaire

Name *

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Last

ID Number *

Email *

Mobile Number *

Do you have any pre-existing medical conditions? If yes, please explain *

Have you been diagnosed with a heart condition and has your doctor ever indicated that you can only partake in certain physical activities? *

If yes, please consult your physician to confirm that the activites you wish to take part in are acceptable and will not affect your physical health.

Do you feel pain in your chest when you perform physical activity? If yes, please explain *

If yes, please consult your physician to confirm that the activites you wish to take part in are acceptable and will not affect your physical health.

Do you have any spinal conditions (i.e. disc protrusion, herniated disc, spondylolisthesis, spurs, or other. If yes, please explain *

Do you have a muscle, nerve, bone or joint problem that could be made worse by any physical activity? If yes, please explain *

Are you pregnant, or do you have reason to believe that you might be pregnant? *

Please note that it is very important to let us know if you are currently expecting. Not all activities offered by the Studio are suitable for expecting mothers.

Do you know of any other health-related reason why you should not engage in physical activity? If yes, please explain *

If you have answered yes (Y) to one or more of the above questions, consult your doctor before engaging in physical activity. The Studio reserves the right to request a medical certificate from a doctor before allowing the Client to engage in the Classes. If you have not had enough space above to complete your answer , please use the space below. *

Emergency Contract *

First

Last

Mobile Number *

Confirmation *

I confirm that I have answered the questions above to the best of my knowledge.

Safety, Conduct, Indemnity and Property – Assumption of Risk and Indemnity *

I confirm that I have read the below and agree to the terms of the studio below.

The Student acknowledges that participation in any aerial arts, pole, dance, fitness, conditioning or related physical activities offered, hosted, facilitated or arranged by the Studio, whether on the Studio’s premises or at any off-site venue, involves inherent physical risks, including but not limited to falls, collisions, equipment failure, muscular strain and injury. The Student confirms that they participate voluntarily and at their own risk and that they are physically fit and medically able to participate, or that they have obtained appropriate medical advice prior to participation. The Student further acknowledges that any pre-existing injury or medical condition may be aggravated by participation. To the fullest extent permitted by law, the Student hereby indemnifies, releases and holds harmless Aerial Flow (Pty) Ltd t/a Flow Studios, The Lyra Project, and their directors, instructors, employees, agents, contractors and representatives from any and all claims, demands, damages, losses, costs or expenses arising from or in connection with the Student’s participation in any Services, whether arising on the Studio’s premises or at any third-party venue, and whether arising from negligence or otherwise. This indemnity applies to all claims, whether foreseen or unforeseen, known or unknown, and shall be binding upon the Student and their heirs, executors, administrators and assigns.

Safety, Conduct, Indemnity and Property – Right of Admission Reserved *

I confirm that I have read the below and agree to the terms of the studio below.

The Studio reserves the right, in its sole discretion, to refuse admission to, suspend or remove any Student or visitor from the Studio’s premises or from any off-site activity or event, without refund, where such person behaves in a manner that is unsafe, disruptive, inappropriate, abusive or in breach of this Agreement, the Studio’s rules or any applicable Terms and Conditions.

Loss or Damage to Personal Property *

I confirm that I have read the below and agree to the terms of the studio below.

The Student acknowledges that any personal property brought onto the Studio’s premises or to any off-site activity or event is done so entirely at the Student’s own risk. The Studio shall not be liable for any loss, theft or damage to any personal belongings, whether arising on the Studio’s premises, in common areas, parking areas, changing rooms, or at any third-party venue where the Studio is offering or facilitating Services.

By typing your name in the box below you hereby sign the form above and attest to it's correctness *

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Last

ID Number of signee *

In the event that the client to whom this form relates is a minor, this form must be completed and signed by a parent or legal guardian.

In the event that the client is a minor, please tick below.

I hereby confirm that I am completing this form on behalf of a minor in my legal care