New Client Group Classes Registration Form

Full Name

First

Last

Email

Phone

EMERGENCY CONTACT INFORMATION

Emergency Contact Name

First

Last

Emergency Contact Phone #

Relationship

Partner, Son, Daughter, Friend, etc.

PAR-Q - Physical Activity Readiness Questionnaire

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

Do you feel chest pain when you do physical activity?

Yes
No

and CONTACT a

In the past month have you had chest pain when you are NOT doing physical activity?

Yes
No

Are you pregnant or have you recently given birth and not yet been cleared for exercise?

Yes
No

Has a physician ever advised you not to participate in physical activity or to exercise only under medical supervision?

Yes
No

Do you CURRENTLY have any injury, illness, pain, dizziness, chest pain, or other medical condition that could make exercise unsafe?

Yes
No

If you answered YES to any of the above questions, please contact us before registering or provide an explanation below:

Have you ever had a serious injury to a bone, joint, muscle, tendon, or ligament that could affect your ability to exercise?

If Yes, please describe the injury, the approximate date (if known), whether it was the RIGHT, LEFT, or BOTH sides, and whether you still experience any pain, stiffness, weakness, or limitations.

Is there anything you should have available during exercise for your safety or comfort (for example: inhaler, glucose source, medication, EpiPen, brace, etc.)?

If yes, please explain.

Is there anything else you want us to know?

Liability Waiver & Informed Consent

I understand that participation in physical activity involves inherent risks, including the possibility of injury, illness, or other adverse outcomes.

I confirm that I am voluntarily participating in group fitness activities provided by Tanya Masse and that I have answered all health screening questions honestly and to the best of my knowledge. I understand that it is my responsibility to participate within my own abilities and fitness level.

I agree to listen to my body and immediately stop participating and notify the coach if I experience pain, dizziness, chest pain, shortness of breath, unusual fatigue, or any other concerning symptoms.

I voluntarily assume the risks associated with participation in these activities and agree to release and hold harmless Tanya Masse, along with any assistants, instructors, or volunteers involved in delivering these activities, from claims arising from my participation.

I acknowledge that I am participating voluntarily, understand the nature of the activities involved, and accept responsibility for my own participation and well-being.

Full Name *ELECTRONIC SIGNATURE

Today's Date

Consent

I have read, understand, and agree to the Liability Waiver & Informed Consent above. I understand that by checking this box, typing my full legal name, and submitting this form, I am providing my electronic signature.

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