Kid's Online Forms
There are 3 sections to this form which need to be filled in before your child attends 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
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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 your child does in their 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 your child takes part in Emily’s Pole Fitness' classes which consist of various poses and tricks using one or all of the following pieces of equipment: aerial silks, aerial hoop, static trapeze 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:
Child's full name *
What does your child like to be called (nickname / preferred name)? *
How old is your child? *
What is your child's date of birth? *
MM
/
DD
/
YYYY
Your child's pronouns (She/Her, He/Him, They/Them, etc) *
I am the child's: *
Your full name *
Your relationship to the child *
Your e-mail address *
Emergency Contact Full Name *
Emergency Contact Phone Number *
1. Does your child have any heart conditions? *
2. Does your child feel any chest pain when they do physical activities?   *
3. In the past month, has your child had chest pain when they were not doing physical activity? *
4. Does your child lose their balance because of dizziness or do they ever lose consciousness?   *
5. Does your child have a bone or joint problem that could be made worse by a change in their physical activity?   *
6. Is your child taking any medication? *
7. Has your child ever been in hospital? *
If you answered Yes to question 7 then please give details here: *
8. Is your child asthmatic or do they have any respiratory problems? *
9. Does your child have any allergies? *
10. Is your child diabetic? *
11.  Is there any reason not mentioned above why any type of physical activity may not be suitable for your child? *
12.  Does your child have any additional needs not detailed above that may require special conditions adjustments? *
If you answered Yes to question 12 then please give details here: *
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 your child can start becoming much more physically active - they will begin slowly and build up gradually.

Please note: If your child's health changes please let their fitness instructor know and ask if it is still safe for your child to participate in classes.
Assumption of Risk:
By ticking this form, I the parent / guardian of therefore mentioned child, hereby state that I have read, understood and answered honestly the questions above.

Please note: Bruises or friction burns may occur due to the nature of these fitness classes. Instructors will physically spot your child during classes for their own safety. Any accidents are always documented and you will be informed.

Furthermore, I the parent / guardian of therefore mentioned child, hereby confirm that my child is 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: *
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