Are you referring someone else in to the project?
If so, please provide your contact details here:
Name of the person attending
*
First Name
Last Name
What is your gender identity?
*
Woman/Girl
Man/Boy
Transwoman/Transgirl
Transman/Transboy
NonBinary/GenderQueer/GenderFluid
Don't Know
Prefer Not To Say
Other
What is your ethnicity?
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Asian or Asian British
Black, Black British, Carribean or African
Mixed or multiple ethnic groups
White
Other ethnic group
Prefer Not To Say
Phone number
*
Email Address
*
Your home postcode
*
Emergency contact name
*
We will contact this person in the event that you become unwell.
First Name
Last Name
Emergency contact number
*
We ask the following questions to help understand and measure our social impact as a charity. Collating this information helps us demonstrate to future funders the success of our club so it’s really important to us and we’d be super grateful for just a moment of your time. We’ll be back in touch with you to ask them again in a few months, in the hope your answers will have improved! : On a scale of 1 to 5, how happy are you right now? (1 is very unhappy, 5 is very happy)
1
2
3
4
5
On a scale of 1 to 5, how active are you in your local community? ie: Do you take part in any other physical exercise or social groups, or do you volunteer? (1 is not active at all, 5 is very active)
1
2
3
4
5
How much time do you spend being active each week? (Being active means getting out of breath doing activity such as an exercise class, walking the dog briskly or gardening etc)
0 minutes
0-30 minutes
30-60 minutes
60-100 minutes
100-150 minutes
150+ minutes
On a scale of 1-5, how optimistic are you about your future? (1 is not very optimistic, 5 is very optimistic)
1
2
3
4
5
Is there anything else you'd like to let us know?
Has your doctor ever said that you have a heart condition and that you should only do physical activity when recommended by a doctor?
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Do you feel pain in your chest when you do physical activity?
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In the past month, have you had a chest pain when you were not doing physical activity?
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Do you lose balance because of dizziness or do you ever lose consciousness?
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Do you have a bone or joint problem that could be made worse by a change in your physical activity?
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Is your doctor currently prescribing you drugs (for example, water pills) for your blood pressure or heart?
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Do you know any other reason why you should not do physical activity?
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If you answered 'yes' to the last question, please provide detail below:
If you answered: ‘Yes’ to one or more questions: You must consult your doctor before undertaking any fitness appraisal, workshop or other exercise routine. You will need to discuss the nature of the activity you are about to undertake and either present your PAR-Q or tell your doctor which questions you answered ‘yes’ to. Your doctor needs to advise you as to your suitability for unrestricted physical activity. ‘No’ to all questions: You acknowledge that you are taking responsibility for the accuracy of your replies and the decision that you are physically fit enough for unrestricted physical activity. By accepting this PAR-Q I undertake that I have read, understood and correctly answered the questions set out above. I wish to participate in activities that may include aerobic, anaerobic, flexibility, stability, resistance, muscular strength and endurance exercise. I realise that my participation in these activities involves the risk of injury and even the possibility of death. I confirm I am voluntarily engaging in a level of exercise that I consider acceptable and appropriate to my level of fitness. If I have answered ‘yes’ to any of the questions above, by signing this form I am also confirming that I have taken medical advice relating to my participation and my doctor has confirmed I am fit enough to participate. Exercise programmes are designed to improve cardiovascular (heart and lungs) fitness, muscle strength and endurance as well as flexibility. Programmes may include physical activities such as running and stretching. Each part of the programme will be fully explained to you but please ask questions if you are not clear about anything. Please notify the instructor if you feel you should not do a particular exercise for any reason. Exercise programmes contain certain risks such as muscle strains, joint sprains, aches, pains and general discomfort from parts of the body not used to exercise. The programme is designed to minimise these risks, however, if at any time during the exercise programme you feel pain, discomfort or you feel unwell you must stop and inform the instructor immediately. I hereby confirm that I have read, understood and answered all the questions on the PAR-Q accurately and to the best of my knowledge. I confirm that I wish to participate in activities and realise that the activities involve an element of risk of injury or even death.
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I ACCEPT
I DON'T ACCEPT
