Adult's Online Forms

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There are 3 sections to this form which need to be filled in before you attend classes. Any information that you provide will not be shared with any third party and will be kept confidential.

Please read and fill in the 3 sections to this form:
1) PAR-Q
2) Terms and Conditions

3) Studio address and parking info

Physical Activity Readiness Questionnaire (PAR-Q)

Regular physical activity is fun and healthy, and the completion of a PAR-Q is a sensible first step to take if you are planning to increase the amount of physical activity in your life. Being more active is safe for most people. However, some people should check with their doctor before they start becoming much more physically active.

Before taking part in Emily’s Pole Fitness Classes which consist of various poses and tricks using one or all of the following pieces of equipment: poles, aerial silks, aerial hoop, static trapeze, aerial pole or poi; and consist of aerobic exercise, dance, toning and muscular strength building exercises, please read the questions below carefully and answer honestly by selecting YES or NO:

Your full name *

What do you like to be called (nickname / preferred name)? *

Your pronouns (She/Her, He/Him, They/Them, etc) *

E-mail *

Emergency Contact Full Name *

Emergency Contact Phone Number *

Your Date Of Birth *

YYYY

1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *

Yes

2. Do you feel pain in your chest when you do physical activity? *

Yes

3. In the past month, have you had chest pain when you were not doing physical activity? *

Yes

4. Do you lose your balance because of dizziness or do you ever lose consciousness? *

Yes

5. Do you have a bone or joint problem that could be made worse by a change in your physical activity? *

Yes

6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? *

Yes

7. Are you pregnant or postnatal? *

Yes

7. If you have answered yes to being pregnant or postnatal:

Please email Emily as you may not be able to attend quite yet. Please refer to our FAQs on our website for our recovery guidelines.

8. Are you asthmatic? *

Yes

9. Are you diabetic? *

Yes

10. Are there any other medical conditions you have that are not mentioned? *

Yes

If you have answered Yes to any of the questions then please provide more details here: *

If you answered NO to all questions:

If you answered NO honestly to all PAR-Q questions, you can be reasonably sure that you can start becoming much more physically active - begin slowly and build up gradually. This is the safest and easiest way to go. Please note: If your health changes please let your fitness instructor know and ask if it is still safe for you to participate in classes.

Assumption of Risk:

I hereby state that I have read, understood and answered honestly the questions above. I also state that I wish to participate in activities that will include various poses and tricks using one or all of the following pieces of equipment: poles, aerial silks, aerial hoop, static trapeze, aerial pole or poi; and consist of aerobic exercise, dance, toning and muscular strength building exercises. I realise that my participation in these activities involves the risk of injury. I also realise that discomforts may occur which include muscular aching, friction burns and bruising. Furthermore, I hereby confirm that I am voluntarily taking part in Emily’s Pole Fitness' Classes and the instructor will not be responsible or liable for any injuries that could be caused as a result of participating in classes.

Please tick below to show that you understand: *

I understand and agree to the Assumption of Risk statement

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