Health Form (PAR-Q)

Student Details:

Firstname:

Club:

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Surname:

D.O.B:

Email:

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

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

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

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

Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a  change in your physical activity?

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

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

Emergency Contact Details

Name:

Address:

Contact Number:

Declaration to be completed by applicant or parent / guardian

I certify to the best of my knowledge and belief, the foregoing details are correct, and in the event of my being accepted I undertake to abide by the constitution and bye laws of the club and the association.

I agree for myself or my child to be photographed or used on the website for promotional use only. Please untick if you do not with for your child or yourself to be photographed.

Signature (please type name)

Date:

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