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Physical Activity Readiness Questionnaire (PAR-Q)

Thank you for your interest in our dance fitness class! Before participating, please complete this short questionnaire to ensure you are ready for physical activity. Your health and safety are our top priorities.

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Please complete the form below

To be completed by 18 years + and over.

Please ensure that all information provided is correct.

First Name

Last Name

Email

Phone

Emergency Contact Full Name

Emergency Contact Phone Number

Please tick all the statements that apply to you as a YES * Required

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 any bone, joint, or muscle problems (e.g., back, knee, hip) that could be made worse by physical activity?

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

Do you have diabetes or any other chronic medical condition that may affect your ability to exercise safely?

Are you pregnant, or have you given birth in the past six months?

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

If you answered TICKED (YES) to one or more questions, please consult your doctor before participating and provide written clearance if required.

Consent & Liability Waiver

I understand that participating in a dance fitness class involves physical activity that may carry a risk of injury. I confirm that I have answered this questionnaire honestly and to the best of my knowledge. By signing below, I acknowledge that I am participating voluntarily and release the instructor, organizers, and facility from any liability related to my participation.

I understand that all classes are subject to being filmed. If you do not wish to be filmed, please let the instructor know at the beginning of the session.

Your Signature

Select a date

Thanks for submitting!

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