“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 *

Disclaimer: Aerial Flow (Flow Studios) take all precautions to ensure the safety of everyone involved. I acknowledge that pole dancing can be strenuous and at times, dangerous. I will rely upon my own judgment in participating in any exercise or manoeuvres. I have been told about the potential risks to my health and freely accept that by participating I run the risk of injury, particularly if I were to fall from, or knock myself on the pole. I will not hold Aerial Flow (Flow Studios liable) fo-r any pre existing injuries or medical condition which may be exacerbated if I participate or which may affect my heart if I participate. I will not hold Aerial Flow (Flow Studios) liable for any injury, loss or damage which may be sustained as a result of participating. I hereby for myself, any heirs, executors, administrators or anyone else who might claim on my behalf, contract not to sue. I waive, release and discharge Aerial Flow (Flow Studios), its staff, agents, subcontractors and representatives of all liability, claims, damage, costs or expenses which I may have against them arising out of or in connection with my participation in the dance and exercise classes. This release extends to all claims of any kind what so ever, foreseen or unforeseen, known or unknown. *

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

By typing your full 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