2024 Contact Info - Health & Registration e-Form for Movement & MELT Classes Online

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Welcome to Jackii's Pilates & Corrective Exercise classes and Love Your fascia MELT treatment sessions.
By filling in this form you are signing up to email updates on what is available to book online at my booking page here (click to go to link)

Your personal data will never be shared with anyone else or passed on to third parties. I have tried to simplify the form with less required fields. This form is required annually to participate in a class.

Thank-you. Enjoy moving well!

PAR Q FORM (Physical Activity Readiness Questionnaire)
Regular physical exercise is fun and healthy and becoming more active is very safe for most people. Please fill in the sections that apply below. Some are mandatory, others are not. If you have any yes responses, please give more details in the following section. If you have any problems please let me know so I can help you. If later on, any condition changes or you develop another issue please let me know and fill out a new form, as each form cannot be edited after submission.

Email *

Name *

Preferred Phone number *

A contact number to call you if a class is unavoidably cancelled at short notice.

Date of Birth *

YYYY

Do you have any medical condition, discomfort or injury which may be affected by physical activity, such as:- a heart condition, angina, high/low blood pressure, dizziness, stroke, epilepsy, diabetes, asthma, an operation within the last 12 months, osteoporosis, back injury, arthritic joints? Or do you suffer from frequent headaches and/or migraines? *

YES

If yes to above please specify any medical condition, discomfort or injury here: -

Do you have any replacement joints*
*

Yes

If yes please specify which joint(s) below: -

Please note – your teacher is not a medical practitioner and cannot advise whether any condition could be adversely affected by attending this class. However your teacher reserves the right to suggest you do not participate in activity until discussion with a medical practitioner has taken place and that in some cases, a letter confirming fitness to participate could be required. The responsibility lies with each participant to decide whether they wish to join or continue with a class, assisted by any medical advice they may wish to obtain.
*

I understand and accept responsibility for my own fitness to participate in an online class.

Required

“I recognise that my body’s reaction to physical activity is not totally predictable. I confirm that should I develop any injury or condition that affects my ability to exercise, I will inform my teacher and stop exercising if necessary. I take full responsibility for monitoring my own physical condition.’’ Please sign by typing your name: -
*

Send me a copy of my responses.

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