Par-Q/Release Of Liability


Par-Q/Release Of Liability

 

Name:       

Address: 

Email:    

Phone:

DOB:    
Age:
Height:  
Weight:
Gender:

Emergency Contact: 

How did you hear about us?

How can we connect with you on Facebook?  

How can we connect with you on Instagram?  

 

Symptoms

1. Has your doctor ever said that you have heart trouble, heart palpitation, coronary disease, or high blood pressure?

2. Do you frequently experience pain or discomfort in the chest or heart area?

3. Do you suffer from shortness of breath at rest or upon mild exertion?

4. Do you suffer dizziness or fainting?

5. Do you have any difficulty breathing?

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

If you answered YES to one or more questions:

Talk to your doctor by phone or in person BEFORE you start becoming much more physically active or BEFORE you have a fitness appraisal. Tell your doctor about the PAR-Q and which questions you answered YES.

  • You may be able to do any activity you want – as long as you start slowly and build up gradually.
  • Or, you may need to restrict your activities to those which are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice.

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.
  • Take part in a fitness appraisal – this is an excellent way to determine your basic fitness so that you can pan the best way for you to live actively.

Note: This physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes so that you would answer YES to any of the questions

Medications and Injuries

What medications are you currently taking?

For what condition(s)?

List any injuries/physical limitations that would limit your ability to exercise or write NONE.

Conditions

Do you now, or have you had in the past year:

Please explain any ;yes' answers below:

Please Describe any past or current musculoskeletal conditions you have incurred such as muscles pulls, sprains, fractures, surgery, back pain or general discomfort :

Lifestyle

Are you taking any supplements or vitamins? if yes which ones:

Do you drink alcohol ?

How Many liters of water do you drink per day?

On a scale from 1-10 how would you rate your stress level ? (1=low, 10=high)

Does you work require you to travel ?

Do you regularly use the service or a massage?

Is anyone overweight in your family ?

Were you overweight as a child ?

Where do you rate your health in your life : 

 

       I understand that Fit With Marine will make every reasonable effort to preserve the privacy of the information

contained in this Client Intake Form. I further agree that Fit With Marine shall not be liable or responsible to

me for any inadvertent disclosure of the information contained in the Client Intake Form and I expressly

release and discharge Fit With Marine from all claims, actions, judgment and the like which I or my heirs,

executors, administrators or assigns may have or claim to have as a result of any damage which may occur in

connection with disclosure of private information contained in the Client Intake Form. This release shall be

binding upon my heirs, executors, administrators and assigns.

 

I have read and understand this term.

 

       I certify that the answers to the questions outlined on the PAR-Q from are true and complete to the best of

my knowledge. I acknowledge that medical clearance is requested if I have answered “Yes” to any of the

questions on the PAR-Q form. I understand and agree that it is my responsibility to inform Fit With Marine

of any condition or changes in my health, now and on going, which might affect my ability to exercise

safely and with minimal risk of injury.

 

I have read and understand this term.

 

 I understand that the results of any fitness program cannot be guaranteed and my progress depends on my effort and cooperation in and outside of the sessions.

 

I have read and understand this term.

Waiver of Liability

Client Name:

Address: 

Email:    

Phone:

Waiver: I have agreed to participate voluntarily in a program of physical exercise and wellness coaching, including, but not limited to, strength training, flexibility development, aerobic exercise, nutritional coaching, and mental wellness coaching, under the guidance of FWM, its authorized agents, employees, and contractor.

In consideration of using the services of Fit With Marine, or herein referred to as FWM, I do hereby release, waive, discharge, and covenant not to sue FWM, its owner, officers, employees, volunteers, and agents, for liability from any and all claims arising from the ordinary negligence of FWM or any of the aforementioned parties. This agreement applies to 1) personal injury from participation in all activities directed, suggested, or planned by FWM either on or off grounds digitally, 2) any and all claims resulting from damage, loss, or theft of property, 3) nutritional recommendations, 4) workouts taking place in the home or other environment of choice of the client.

Indemnification and Hold Harmless: I also agree to hold harmless and indemnify FWM, and any of its previously mentioned parties, from all claims and to reimburse them for any expenses incurred as a result of my involvement with FWM. I further agree to pay all expenses, including court costs and attorney’s fees, incurred by FWM and the aforementioned parties in investigating and defending a claim or suit resulting from my participation in any FWM conditioning activities.

Assumption of Inherent Risks: I understand that Fitness and conditioning activities, such as weight lifting, stretching, and many aerobic exercises, have certain inherent risks that may not be eliminated, regardless of the care of the personal trainer. Some of these involve strenuous exertions, quick movements, or sustained physical activity that places stress on the cardiovascular system.

Risks may involve, but are not limited to, 1) minor injuries, such as scratches, bruises, muscle strains, and sprains, 2) major injuries, such as ligament damage, broken bones, joint or back injuries, concussions, and heart attacks, 3) very rare occurrence of paralysis or death.

In addition, many activities will involve equipment, all of which have the potential of malfunctioning or causing injury. I will provide the equipment or machinery to be used in connection with workouts, including, but not limited to, benches, dumbbells, barbells, resistance bands, stability training devices and similar items (“Equipment”). I will have control over the area in which we perform our workouts. I represent and warrant any and all Equipment I provide for training sessions (“My Equipment”) is for personal use only. FWM has not inspected my Equipment and has no knowledge of its condition. I understand I take sole responsibility for My Equipment. I acknowledge that My Equipment (“My Equipment”) may malfunction and/or cause Injuries and Changes (as defined in the Waiver) and that I take sole responsibility to inspect any and all of My Equipment

Acknowledgement of Understanding: I hereby affirm that I am in good physical condition and do not suffer from any known disability or condition which would prevent or limit my participation in these exercise programs and training.

I take full responsibility for my own health and safety in participating and to the extent I deem advisable, will consult a physician before participating in any of the activities. If I have chosen not to obtain a physician’s consent prior to beginning any and all programs and training with FWM, I hereby agree that I am doing so solely at my own risk.

I understand that it is my sole responsibility to participate in exercises that are appropriate for the current status of my health. If I have any questions or concerns about whether or not a particular activity is appropriate, I understand it is my responsibility to seek advice from my doctor or GP.

I understand that this program is not medically supervised, and exercise activities and coaching are delivered online and so are I am not overseen.

I have read these assumptions of risks and fully understand its terms. I recognize the demands of those activities relative to my physical condition and skill level, and I appreciate the types of injuries that may occur as a result. I understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing the agreement freely and voluntarily and intend my signature to signify a complete and unconditional assumption of the inherent risks in any way associated with the personal training program offered by FWM.

Media Release (Optional): I authorize FWM to use, reproduce, and/or publish photographs and/or video that may pertain to me- including my image, likeness and/or voice without compensation. I understand that this material may be used in various publications, recruitment materials, broadcast public service advertising (PSAs) or for other related endeavors. This material may also appear on the Internet Web Page. This authorization is continuous and may only be withdrawn by my specific repeal of this authorization. Consequently, FWM may publish materials, use my name, photograph, stats, and/or make reference to me in any manner that FWM deems appropriate in order to promote/publicize service opportunities.

Leave this empty:

Signature arrow sign here

Signed by Marine Giguet
Signed On: May 6, 2022


Signature Certificate
Document name: Par-Q/Release Of Liability
lock iconUnique Document ID: 087d9bfb6b7baf88cc55b4d21fe142e6430f9964
Timestamp Audit
February 3, 2022 5:56 pm +04Par-Q/Release Of Liability Uploaded by Marine Giguet - marineg.trainer@gmail.com IP 104.11.254.244