ResiliBOD (Tuesdays) Registration

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(Formerly Total Body Tuesday)

May 7 - June 25 at 7PM (No class on June 4)

7-week program

The Ross Creek Annex

2182 Sheffield Rd, Canning

Registration fee: $45

Optional child care: $35 per child
Questions: resilifitcoaching@gmail.com

Name (first and last) *

Gender Pronouns

Email address *

Phone number *

Are you over the age of 18? *

Yes

Emergency contact name (first and last) *

Relationship *

Emergency contact phone number *

I will require childcare for the following child(ren):

We occasionally take photos or videos of participants during our hikes, which could then be used in our educational or promotional materials. By consenting below, you are granting permission for resiliFIT Coaching to use still photographs or videos for this participant for these purposes only. *

Yes

Heath questionnaire

Has your doctor ever said that you have a heart condition and that you should only perform medically supervised physical activity?
*

Yes

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

Yes

In the past month, have you had chest pain when you were not performing any 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 problem that could be made worse by a change in your physical activity?
*

Yes

Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?
*

Yes

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

Yes

Please check the box that applies to you below:
*

I answered NO to all questions above, and I have been cleared by my healthcare provider for exercise.

I answered NO to all questions above, and I have NOT been cleared by my healthcare provider for exercise.

I answered YES to one or more questions above, my healthcare provider is aware of these health conditions, and they have cleared me for exercise.

I answered YES to one or more questions above, and I have NOT been cleared by my healthcare provider for exercise.

Required

If you checked box 1 or 3, please sign the release below.

If you checked box 2 or 4, I highly recommend getting clearance from your healthcare provider before starting an exercise program. Please ask them to provide a signed clearance form and give it to me, along with this PAR-Q form.

Disclaimer and Release

I, the undersigned, have read, understood to my full satisfaction, and completed this questionnaire.

I understand that if my health changes, I must inform resiliFIT Coaching and check with my healthcare provider that I’m still cleared for exercise.

I recognize that it is my responsibility to work directly with my healthcare provider before, during, and after seeking fitness and/or nutrition consultation.

I understand that any information provided is not to be followed without prior approval of my family doctor or other healthcare professional. If I choose to use this information without such approval, I agree to accept full responsibility for my decision.

I understand that there is inherent risk associated with physical activity such as but not limited to: episodes of transient lightheadedness, fainting, abnormal blood pressure, and musculoskeletal injuries, and I assume wilfully those risks, and consent to participate in any physical activity involved with the delivery of the group fitness class (virtual or in-person).

I understand that the class instructor has the right to stop me from doing exercise which they feel would be harmful to me or make me stop exercising upon observation of any symptoms of distress or abnormal response.

I understand that it is my obligation to immediately inform the class instructor of any unusual pain, discomfort, fatigue, or any other symptoms that I may suffer during or immediately after physical activity.

I acknowledge that use of personal exercise equipment brought from home is my responsibility to maintain and ensure it is safe for use during classes offered by resiliFIT Coaching. Further, I acknowledge that using personal equipment outside of regular class requirements (such as free weights or other equipment not required) is done so by my own choosing and is not the responsibility or liability of resiliFIT Coaching or its trainers and class facilitators. Though the exercises I use my personal equipment for may be similar to those performed in class, I waive liability to resiliFIT Coaching for any injury caused while using my personal equipment.

I hereby release resiliFIT Coaching and the class instructor from any liability with respect to damage or injury (including death) that I may suffer during participation in physical activity during the group fitness class except where the damage or injury is caused by the gross or wilful negligence of the class instructor or resiliFIT Coaching within the scope of their duties.

I acknowledge that my coach may retain a copy of this form for their records. In these instances, they will maintain the confidentiality of the same, complying with applicable law.

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Date *

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Would you like your email to be added to the monthly newsletter? *

Yes

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