Metacubs PAR-Q Stern Training

Welcome sheet - Client information
Full name*
First NameLast Name
Male or Female
MaleFemale
Date of birth
DayMonthYear
Date
Childs Name
First NameLast Name
Date of Birth
DayMonthYear
Date
Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Phone Number
Phone number
E-mail*
example@example.com
Client information - Health questionnaire (Par-Q)
Please read the questions carefully and answer each one honestly:YES, NO or N/A

Par-Q*

	Yes	No	N/A
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 be 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?
Have you had a baby in the last 6 weeks and has the Doctor or midwife given you permission to exercise?
Are you taking any medication from your doctor?

Par-Q for child*

	Yes	No	N/A
Does the child attending have a heart condition that the doctors has identified they should only do physical activity recommended by a doctor?
Do they feel pain in their chest when they do physical activity?
Do they lose balance because of dizziness or do they ever lose consciousness?
Do they have bone or joint problem (for example, back, knee, or hip) that could be worsen by a change in your physical activity?
Do you know of any other reason why they should not do physical activity?
Are they taking any medication from their doctor?

If you answered yes to any of the above, please give details below.
I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction.
Initials*
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Client information - Liability waiver
I am aware of the risks in observing or participating in the activities offered by Stern Training and I understand that all sports or fitness that I will execute and participate in are entirely at my own risk and perils. I assume complete responsibility and liability for those risks and for the injuries that may occur as a result of these risks, even if injuries occur in a manner that is not foreseeable at the time I sign this agreement. I realise that by voluntarily assuming the risks involved, I will be solely responsible for any loss or damage I sustain, including personal injuries to me or damage to my property. I understand that it is my sole responsibility for the health and safety of the young person/child I have brought with me to attend this class and Stern Training holds no liability.
Client informations - Signature
Signature*
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Date
DayMonthYear
Date
Should be Empty:

Welcome sheet - Client information