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Medical Waiver

Full Name: {name} 

Guardian of Member (if applicable):

Date of Birth:  

Address:  

Post Code:  

Contact Number:  

Emergency Contact:  

Relation to emergency contact:  

Emergency Contact mobile number:  

Please complete the questions below to ensure your health is in good condition to commence training with the Academy. 

1. Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?  Yes  No  
2. Do you feel pain in your chest when you do physical activity?  Yes  No  
3. In the past month, have you had a chest pain when you were not doing physical activity?           Yes  No  
4. Do you lose balance because of dizziness or do you ever lose consciousness?                           Yes  No  
5. 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?   Yes  No  
6. Is your doctor currently prescribing medication for your blood pressure or heart condition? Do you know of any other reason why you should not take part in physical activity?                                 Yes  No  

If you answered YES to one or more questions:

You should consult with your doctor to clarify that it is safe for you to become physically active at this current time and in your current state of health.
If you answered NO to one or more questions:
It is reasonably safe for you to participate in physical activity, gradually building up from your current ability level. A fitness appraisal can help determine your ability levels.

By completing this form, you are accepting full responsibility and liability of any accident and injuries that may occur during training. The Academy, teachers and any of its personnel will not be held liable or responsible.

I have read, understood and accurately completed this questionnaire. I confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury.

Having answered YES to one of the questions above, I have sought medical advice and my GP has agreed that I may exercise.
Note: This PAR Q becomes invalid if your condition changes so that you would answer YES to any of the 7 questions

I have read, understood and accurately completed this