Exercise Class Participant Questionnaire

Client Information
Full name*
First NameLast Name
Birth Date
DayMonthYear
Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
E-mail*
example@example.com
Phone Number*
Format: (000) 000-0000.
Emergency Contact Name*
First NameLast Name
Emergency Contact Phone number*
Format: (000) 000-0000.
Health questionnaire (Par-Q)
Common sense is your best guide when you answer this questionnaire. Please read the questions carefully and answer each one honestly: check YES or NO.

Par-Q*

Rows	Yes	No
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose balance because of dizziness or do you ever lose consciousness?
Do you have bone or joint problem (for example, back, knee, or hip) that could worsen by a change in your physical activity?
Is your doctor currently prescribing drugs (for example water pills) for blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?
Are you pregnant or have given birth in the past 6 months?
Do you have any injuries?
Do you take any medication?
Do you suffer from back pain?

Please provide any further details here:
I have read, understood and completed this questionnaire to the best of my knowledge.
(Initial in this box as if you have a pen in your hand rather than type)
Initials*
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Liability waiver
I am aware of my own health and physical condition, and having knowledge that my participation in any exercise program may be injurious to my health, am voluntarily participating in a physical activity.

Having such knowledge, I hereby acknowledge this release, any representatives, agents and successors from liability for accidental injury or illness which I may incur as a result of participating in the said physical activity. I hereby assume all risks connected therewith and consent to participate in said program.
(Initial in this box as if you have a pen in your hand rather than type)
Initials*
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Cancellation Policy
All cancellations must be received at least 12hrs before your class or training session to enable you to rebook for a later date. Clients who do not cancel with 12hrs notice will be unable to rebook and will lose the fee for that session/class.
Refunds are not given.
CH Fitness understands that emergencies happen. We provide every client with one free short-notice cancellation. You will not be charged for your first cancellation with less than 12hrs notice. Subsequent short notice cancellations will be charged for the session. The free short-notice cancellation only applies if CH Fitness is given notice prior to the session start time. No shows are not eligible for the free cancellation.
(Initial in this box as if you have a pen in your hand rather than type)
Initials*
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Date
JourMoisAnnée
23
Should be Empty:

Client Information

Health questionnaire (Par-Q)

Liability waiver

Cancellation Policy