TEEN PAR-Q CPR HEALTH & FITNESS

Parent/guardian name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Date of Birth *

MM

DD

YYYY

Does your child have or has he/she ever experienced the following *

High or low blood pressure

Elevated blood cholesterol

Diabetes

Chest pains brought on by physical exertion

Childhood epilepsy

Dizziness or fainting

A bone, joint or muscular problems with arthritis

Asthma or other respiratory problems

Any sustained injuries or illness

Any allergies

Is your child taking any medication?

Has your doctor ever advised your child not to exercise?

None

Is there any reason not mentioned above why any type of physical activity may not be suitable for your child? *

Yes

No

Name and address of Health Centre *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

In signing this form, I the parent/guardian of the aforementioned child, affirm that I have read this form in its entirety and I have answered the questions accurately and to the best of my knowledge. I understand that my child is responsible for monitoring him or herself throughout the activity and should any unusual symptoms occur, would cease participation and inform the instructor. In the event that medical clearance must be obtained prior to my child's participation in an exercise session, I agree to contact the GP and obtain written permission prior to the commencement of the exercise activity, and that this permission be given to the instructor. *

I agree

Parent/guardian name *

First Name

Last Name

The data collected on this form is done so in line with our privacy policy notice for members. Please ensure you have read and understood our privacy policy in full before signing this form. The privacy notice sets out the legal basis for processing this data, how we protect your personal information and your rights in relation to the personal data that we hold on you. A copy of the policy can be found on our website www.cprhealthandfitness.com