Aqua Fitness Class with Quiana

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Aqua Fitness Class with Quiana - REGISTRATION

Thank you for your interest in the FitTastic Health Aqua Fitness Class. Please complete the below questionnaire to tell me a little information about you.

I'm looking forward to a Siuper FitTastic and memorable session with you and the class.

Let's do this!

Have a Super FitTastic Day!

Quiana Canfor-Dumas

Email *

Name *

Phone Number

City/Area *

How did you hear about the Aqua Fitness Class? *

Have you ever participated in a water aerobics class? If so, when was your last class? *

Do you currently participate in regular exercise programs? If so, what? How often? How many minutes per session? *

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

Do you know of any other reason why you should not do physical activity? *

Yes

How is your stress level? *

Low-Moderate, I'm managing well.

Moderate-High, I have coping strategies.

Extremely High, sometime I feel like I'm on the brink of a breakdown.

Do you have any additional information you would like to share about yourself?

Photo & Video Consent:

I understand that photos and videos will be taken to help encourage and inspire others to a lifestyle of wellness and fitness. My participation in this class could help to transform the lives of many others.

Yes. I consent to the use of my pictures and/or videos taken during class. I want to be an inspiration to others.

No. I do NOT consent to the use of my pictures and/or videos taken during class. I'll inspire others a different way.

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Informed Consent for Class Participation:

The goal of the FitTastic Health Aqua Fitness Class is to provide an effective and safe exercise experience for all participants. I understand that each person (myself included) has a different capacity for participating in physical activity. I assume full responsibility during and after my participation, for my choices to use or apply, at my own risk, any portion of the information or instruction I receive.

During my participation in this exercise class, it is my obligation to stop exercising if I experience any symptoms of fatigue, shortness of breath, chest discomfort, or similar occurrences. It is also my responsibility to stop exercising if I experience back pain, neck pain, or any other pain. It is my responsibility to inform the instructor of any symptoms , should any develop.

I understand that there exists the remote possibility during exercise of adverse changes including abnormal blood pressure, fainting, disorders of heart rhythm, and in very rare instances heart attack or even death. I understand that every effort will be made to minimize these occurrences by proper staff assessment of my condition before each exercise session, by staff supervision during the session, and by my own careful control of exercise efforts. I understand that there exist a risk of injury, heart attack, or even death as a result of my exercise, but knowing those risks, I desire to participate as herein indicated in the Aqua Fitness Class.

I consent

I do NOT consent

Send me a copy of my responses.

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