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PARQ – Physical Activity Readiness Questionnaire & Safety Agreement

AGE ACTIVITY FITNESS CLUB

New Member Registration & Health Check

Strength Through Health
Please complete this form before your first class. Coach Ced will review your health screening information before participation.

1. Select Your Age Activity Class
2. Your Personal Details
3. Emergency Contact
4. Health & Exercise Readiness

Answer all seven questions. A “Yes” answer does not necessarily mean you cannot take part, but Coach Ced may need to discuss it with you before you exercise.

1. Has a doctor advised that you should only exercise under medical supervision?

2. Do you experience chest pain during physical activity?

3. Have you experienced chest pain while at rest during the last month?

4. Do you experience dizziness, fainting or significant balance problems?

5. Do you have a bone, joint, knee, hip or back problem that could be affected by exercise?

6. Are you taking medication for blood pressure, a heart condition, diabetes or dizziness?

7. Is there any other health reason why exercise may not be suitable for you today?

5. Additional Health Information

If you have chest pain, fainting or other concerning symptoms, seek appropriate medical advice before exercising.

6. Exercise Participation Agreement

I understand that exercise involves physical effort and some risk. I will work within my abilities, follow safety instructions, and tell the coach if I feel unwell or if my health circumstances change. I understand that submitting this form does not automatically confirm that I am ready to participate.

7. Privacy, Health Information & Optional Media Consent
How your information is used

Your registration and health answers are collected by Keep Well Nutrition & Health / Age Activity Fitness Club to manage participation and exercise safety. Access is restricted to authorised personnel.

Please read our privacy policy before submitting. It explains how your information is used, protected and retained, and your data protection rights.

Privacy notice: Read our privacy notice

Health information consent *

If you do not provide the health information needed for exercise screening, we may be unable to assess whether you can participate safely. Please read the privacy notice for further information.

Photographs and videos (optional)

Media consent is optional and does not affect attendance. If you agree, identifiable photos or videos may be used on our website, Facebook, Instagram, YouTube, TikTok and printed promotional materials. You may withdraw permission for future use by contacting us; previously shared copies may not always be removable.

8. Declaration & Electronic Signature

I confirm that the information I have provided is accurate to the best of my knowledge.

A new tab will open with your submission confirmation. Please do not submit the form twice unless instructed.