• Epik Chiro Education Course Registration Information

  • Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • PAR-Q (Physical Activity Readiness Questionnaire)

    Select Yes or No for the following questions:

  • 1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?*
  • 2. Do you feel pain in your chest when you do physical activity?*
  • 3. In the past month, have you had chest pain when you were not doing physical activity?*
  • 4. Do you lose your balance because of dizziness or do you ever lose consciousness?*
  • 5. Do you have a bone or joint problem that could be made worse by a change in your your physical activity?*
  • 6. Is your doctor currently prescribing medication (e.g. water pills, beta blockers, etc.) for a blood pressure or heart condition?*
  • 7. Do you know of any other reason why you should not participate in physical activity?*

  • I have answered the PAR-Q accurately and completely. I understand that my medical history is a very important factor in the development of my fitness/wellness program. I understand that certain medical or physical conditions which are known to me, but which I do not disclose to Epik Chiro may result in serious injury to me. If any of the above conditions change, I will immediately inform Epik Chiro of those changes. I knowingly and willingly assume all risks of injury resulting from my failure to disclose accurate, complete and updated information in accordance with the above questionnaire.

  • I understand that I am responsible for (Initial next to each line):

  • Informed Consent of Training & Education Program

    Description of Potential Risks: I understand that no exercise program is without inherent risks regardless of the care taken by an instructor and that my personal safety cannot be guaranteed by my instructor. I realize that when participating in any exercises, particularly those that induce cardiovascular stress, there is change of serious injury (e.g. heart attack, stroke, or other cardiovascular accidents) or catastrophic incident (e.g. death, paralysis Likewise, I know that engaging in muscular endurance, strength building, and other fitness activities sometimes results in minor injuries (e.g. bruises, musculoskeletal strains and sprains), less frequently, more serious injuries (e.g. muscle tears, herniated discs, torn rotator cuffs, etc and rarely, catastrophic injury (e.g. death, paralysis

    Participant Responsibilities: I understand that it is my responsibility to:

    1. fully disclose any health issues or medications that are relevant to participation in a strenuous exercise program;
    2. cease exercise and report promptly any unusual feelings (e.g. chest discomfort, nausea, difficulty breathing, apparent injury) during the exercise program; and
    3. clear my participation with my physician.

    Participant Acknowledgements: Agreeing to this exercise & education program I acknowledge that my participation is completely voluntary. I understand the potential physical risks involved in the exercise program and believe that the potential benefits outweigh those risks. I give consent to certain physical touching that may be necessary to ensure proper technique and body alignment. I understand that the achievement of my health, fitness, or education goals cannot be guaranteed. I have had a voice in planning and approving the activities selected for my exercise program. I have been able to ask questions regarding any concerns I might have, and have had those questions answered to my satisfaction. | am in good physical condition, have no impairment, which might prevent my participation in such activities, and have been advised to consult a physician prior to beginning this program. | have been advised to cease exercise immediately if I experience unusual discomfort and feel the need to stop.

  • I have read and understand the above agreement; I have been able to ask questions regarding any concerns I might have; I have had those questions answered to my satisfaction; and I am feely signing this agreement.

  • Date of the Signature*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date of the Signature*
     / /
    2 digit month, 2 digit day, 4 digit year
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  • Should be Empty: