PAR-Q Form and Agreement - Synergy Fitness and Movement

Synergy Fitness - PAR-Q & Agreement

First Name

Last Name

1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

Yes

2. Do you feel pain in your chest when you do physical activity?

Yes

3. In the past month, have you had chest pain when you were not doing physical activity?

Yes

4. Do you lose your balance because of dizziness or do you ever lose consciousness?

Yes

5. Do you have a bone or joint problem that could be made worse by a change in your physical activity?

Yes

6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?

Yes

7. Do you know of any reason why you should not do physical activity?

Yes

PARTICIPANT'S AGREEMENT, RELEASE AND ACKNOWLEDGEMENT OF RISK

We thank you for your continued support and membership in our health club facility. In an effort to provide you with opportunities to maximize your fitness goals, we would like to solicit your input. Your observations and opinions are a valuable resource that we would like to utilize. We are asking that you agree to notify us if you become aware of any problems or defective equipment at this facility. This is your club and your chance to participate in its management. We would also like to remind you that this is your responsibility to make certain that your exercise program is the right one for you. You must consult with your physician before beginning or modifying any exercise regime.

I warrant that I am in good health and that I have notified the club of any pre-existing medical conditions that I have.

The storage of valuables is at my own risk.

If equipment is defective, I will not use it and I will report its condition to a staff member of the club.

I expressly agree and promise to accept and assume all of the risks existing in this activity. My participation in this activity is purely voluntary and I elect to participate in spite of the risks.

I hereby voluntarily release, forever discharge and agree to indemnify and hold harmless Synergy Fitness and Movement, for any and all claims, demands, or causes of action, which are in any way connected with my participation in this activity or my use of Synergy Fitness and Movement's equipment or facilities, including any such claims which allege the negligent acts or omissions of Synergy Fitness and Movement.

Should Synergy Fitness and Movement or anyone acting on their behalf, be required to incur attorney's fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs.

In the event that I file a lawsuit against Synergy Fitness and Movement, I agree to do so solely in the state of Florida, and I further agree that the substantive law of that state shall apply in that action without regard to the conflict of law rules of that state.

By my signature below, I acknowledge that I have read the foregoing, understand it and agree to the terms.

First Name

Last Name

Date

*If under 18, signature of parent or guardian is required:

Parent/Guardian Print Name

Parent/Guardian Phone

Parent/Guardian Address

THANK YOU FOR CHOOSING SYNERGY FITNESS TO HELP YOU ACHIEVE YOUR FITNESS GOALS.

REFERRALS: If you have a friend or relative, who could benefit from our program, please list their name and phone number below. If they purchase a package of one month or greater we will deduct $50.00 from your next bill.

Referral Name

Referral Phone

First Name

Last Name

First Name

Last Name

First Name

Last Name

First Name

Last Name