Questionnaire

Please fill out the following disclaimer, consent and physical activity readiness questionnaire and I will be in touch!

Contact Details

Name(required)

Email(required)

Phone(required)

Date of Birth(required)

Address(required)

Emergency Contact Details

Emergency Contact Name(required)

Emergency Contact Telephone(required)

The Physical Activity Readiness Questionnaire

Please read the 7 questions below carefully and answer each one honestly

1. Has your doctor ever said that you have a heart condition or high blood pressure?(required)

Yes No

2. Do you feel pain in your chest at rest, during your daily activities of living or when you do physical activity?(required)

Yes No

3. Do you lose balance because of dizziness or have you lost consciousness in the last 12 months? Please answer no if your dizziness was associated with over-breathing (including during vigorous exercise)(required)

Yes No

4. Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? Please list conditions below(required)

Yes No

Existing conditions (if applicable)

5. Are you currently taking prescribed medications for a chronic medical condition? Please list condition(s) and medications below(required)

Yes No

Existing condition(s) and medications if applicable

6. Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? Please answer no if you had a problem in the past, but it does not limit your current ability to be physically active. Please list condition(s) below(required)

Yes No

Existing condition(s) if applicable

7. Has your doctor ever said that you should only do medically supervised physical activity?(required)

Yes No

If you answered NO to all of the questions above, you are cleared for physical activity.

If you have answered ‘YES‘ to one or more questions above talk to your doctor by phone or in person before you start becoming more physically active and before you have a fitness assessment.

Tell your doctor about the questionnaire and which question(s) you have answered yes to. You may be able to do any activity you want – as long as you begin 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 kind of activity you wish to participate in and follow his/her advice.

If you have answered ‘NO‘ to all questions above you can be reasonably sure that you can start to become more physically active and take part in a suitable exercise program. Remember – begin slowly and build up gradually.

Please note: If your health changes so that subsequently you answer ‘YES‘ to any of the above questions, inform your fitness or health professional immediately. Ask whether you should change your physical activity or exercise plan. Delay becoming more active if you feel unwell because of a temporary illness such as flu – wait until you are better.

Informed Consent

The programme will be based upon your present activity/exercise levels and the goals that you wish to achieve. You will experience some feelings of exertion during each activity session and will become hot and uncomfortable at times, if your plan includes certain types of cardiovascular exercise. Your breathing and heart rate will increase as a result of these activities as would be expected from physical exercise of this type. As your fitness improves, you will participate in more vigorous levels of activity if this is part of your goal, but these will be within your capabilities.

Activities will be explained and/or demonstrated either in person or video (depending on service that has been opted for) but please feel free to ask questions about anything you wish.

If, at any time, you feel undue pain or excessive discomfort stop the activity and inform me of your symptoms. You are free to withdraw from any activity at any time you wish.

Timekeeping

Training sessions will last between 45-65 min. Please arrive on time, as I will have to cut the training short because another client may be booked immediately after you. Please let me know as soon as possible if you are running late.

Cancellation

I will need 24 hour notice if you wish to cancel or reschedule the session. This is to enable rebooking the time slot for another client. If you will fail to provide 24 hour notice, the session will be charged in full.

Disclaimer

ASSUMPTION OF RISK, WAIVER AND RELEASE OF LIABILITY, AND INDEMNITY AGREEMENT DECLARATIONS

This Agreement is entered into between Instructor Olga Whiting (“Instructor”) and the undersigned (“Client”). The provision of training services by Instructor to Client, and Client’s use of any premises, facilities or equipment are contingent upon this Agreement.

ASSUMPTION OF RISK

You agree that if you engage in any physical exercise or activity, including training, or enter our premises or use any facility or equipment on our premises for any purpose, you do so at your own risk and assume the risk of any and all injury and/or damage you may suffer, whether while engaging in physical exercise or not. This includes injury or damage sustained while and/or resulting from using any premises or facility, or using any equipment, whether provided to you by Instructor or otherwise, including injuries or damages arising out of the negligence of Instructor, whether active or passive, or any of Instructor’s affiliates, employees, agents, representatives, successors, and assigns. Your assumption of risk includes, but is not limited to, your use of any exercise equipment or other areas, sidewalks, parking area, stairs, shower, or other general areas of any facilities, or any equipment. You assume the risk of your participation in any activity, program, instruction, or event, including but not limited to weightlifting, walking, jogging, running, aerobic activities, or any other sporting or recreational endeavor. You agree that you are voluntarily participating in the aforementioned activities and assume all risk of injury, illness, damage, or loss to you or your property that might result, including, without limitation, any loss or theft of any personal property, whether arising out of the negligence of Instructor or otherwise.

RELEASE

You agree on behalf of yourself (and all your personal representatives, heirs, executors, administrators, agents, and assigns) to release and discharge Instructor (and Instructor’s affiliates, related entities, employees, agents, representatives, successors, and assigns) from any and all claims or causes of action (known or unknown) arising out of the negligence of Instructor, whether active or passive, or any of Instructor’s affiliates, employees, agents, representatives, successors, and assigns. This waiver and release of liability includes, without limitation, injuries which may occur as a result of (a) your use of any exercise equipment or facilities which may malfunction or break, (b) improper maintenance of any exercise equipment, premises or facilities, (c) negligent instruction or supervision, including training, (d) negligent hiring or retention of employees, and/or (e) slipping or tripping and falling while on any portion of a premises or while traveling to or from training, including injuries resulting from Instructor’s or anyone else’s negligent inspection or maintenance of the facility or premises.

INDEMNIFICATION

By execution of this agreement, you hereby agree to indemnify and hold harmless Instructor from any loss, liability, damage, or cost Instructor may incur due to the provision of training by Instructor to you.

ACKNOWLEDGMENTS

You expressly agree that the foregoing release, waiver, assumption of risk and indemnity agreement is intended to be as broad and inclusive as permitted by the law in the UK and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. You acknowledge that Instructor offers a service to her clients encompassing the entire recreational and/or fitness spectrum. This release is not intended as an attempted release of claims of gross negligence or intentional acts. You acknowledge that you have carefully read this waiver and release and fully understand that it is a release of liability, express assumption of risk and indemnity agreement. You are aware and agree that by executing this waiver and release, you are giving up your right to bring a legal action or assert a claim against Instructor for Instructor’s negligence, or for any defective product used while receiving training from Instructor. You have read and voluntarily signed the waiver and release and further agree that no oral representations, statements, or inducement apart from the foregoing written agreement have been made.

Final Agreement and Acknowledgement

I hereby state that I have read, understood and answered honestly the questions above. I wish to participate in physical activities that may include aerobic exercises, resistance exercises and flexibility exercises. I realise that in participating in these activities I may be at risk of an injury and even the possibility of death. I hereby confirm that I am participating voluntarily.

Do you agree?(required)

Yes No

Initials*(required)

Electronic Signature Consent(required)

By checking here you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here you are waiving that right. After consent you may, upon written request, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.