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TEEN PAR-Q
TEEN PAR-Q
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Description
About you
The information in this section is about the TEEN
First name
*
Last name
*
Email address
*
Phone
*
Date of birth
*
Day
Select day
1
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31
Month
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1
2
3
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5
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7
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Year
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1943
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1938
1937
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1931
1930
School year
*
Street Address
City
Postcode
Country
Afghanistan
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Anguilla
Antarctica
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Kosovo
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Mali
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Nigeria
Niue
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Panama
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Stateless Persons
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Uruguay
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Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna Islands
Western Sahara
Yemen Arab Rep.
Yemen Democratic
Zambia
Zimbabwe
Parent/Guardian
Emergency contact
Name and surname
*
Relationship
*
Mobile phone number
*
Physical Activity Readiness Questionnaire (PAR-Q)
Does your child have or have they ever experienced any of the following:
High or low blood pressure
*
Yes
No
Elevated blood cholesterol
*
Yes
No
Diabetes
*
Yes
No
Chest pains brought on by physical activity
*
Yes
No
Childhood epilepsy
*
Yes
No
Dizziness or fainting
*
Yes
No
A bone, joint or muscular problem with arthritis
*
Yes
No
Asthma or other respiratory problems
*
Yes
No
Any sustained injuries or illness
*
Yes
No
Any allergies
*
Yes
No
Is your child taking any medication
*
Yes
No
Has your doctor ever advised your child to exercise
*
Yes
No
Is there any reason not mentioned above why any type of physical activity may not be suitable for your child?
*
Yes
No
If you answered yes to any of the previous question, please provide full details here:
Terms and conditions
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 declare to the best of my knowledge of no reason why my child should not participate in a personalised programme entirely at their own risk and waive any legal recourse for damages or property arising from their participation. I understand that my child is responsible for monitoring him or herself throughout any 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 understand that if my child fails to behave in a manner that is polite and social, and does not abide by ace lifestyle regulations, he or she could be removed from that particular activity.
Signed
*
In consideration of being able to take part in exercise and physical activity organised by ace lifestyle, I acknowledge that I am physically fit for participating in ace lifestyle activities. I agree to abide by all verbal and written notices regarding safety whilst exercising with ace lifestyle. ace lifestyle shall not be liable for any injury or death I may suffer in these activities.
Signed
*
Full Name
*
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