Waivers app for physical activity diffused across Europe and the Americas.

PRE-ACTIVITY QUESTIONNAIRE

In preparation for your water cycling class please tell us about your existing medical and physical conditions, and who to contact in an emergency. It is your responsibility to complete this form before participating in a water cycle class. For any conditions that can be affected by exercise, please consult your doctor and obtain a written medical clearance to exercise. The information contained will be treated as confidential and only revealed to relevant team players (staff) for your safety.

CONTACT DETAILS

Name: * Please enter your name.

Mobile Phone: * Please enter your phone number.

EMERGENCY CONTACT

Name: * Please enter your name.

Telephone (h) * Please enter your phone number.

Telephone (w) Please enter your phone number.

Any other conditions? Please describe below. Please enter your answer here.

Any other? Please describe below. Please enter your answer here.

ARE YOU CURRENTLY TAKING ANY MEDICATION? *

Yes

No

Please select at least one choice above.

If Yes, Please describe below. Please enter your answer here.

ARE YOU, OR HAVE YOU RECENTLY BEEN PREGNANT? *

Yes

No

Please select at least one choice above.

If Yes, Please describe below. Please enter your answer here.

ARE YOU CURRENTLY EXERCISING? *

Yes

No

Please select at least one choice above.

If Yes, What type of exercise? If No, have you in the past? what type? Please enter your answer here.

What is the intensity of your current exercise, or what was it in the past (if applicable)

Easy/light

Moderate

High intensity/hard

Please select at least one choice above.

How many times per week? (If applicable) Please enter your answer here.

Can you swim? *

Yes

No

Please select at least one choice above.

I understand that I may participate in physical activities which may expose me to certain risks and that I do so at my own risk. I will not hold Water Resist, or any of its servants and agents, liable for any injury, loss, damage or death caused to me or my property whether by negligence, omission, and breach of contract or in any way whatsoever. * Please check it here.

I, as the name listed below

Please fill your name: *

Please enter your full name.

undertake to complete a new pre-activity questionnaire in the event of any change in my medical status during the course. I understand that it is my responsibility to advise Water Resist of any medical/physical conditions that may prevent me from exercising and that I participate in exercise at my own risk.

Signed *

Click to sign

Please sign here.

Date *

Please enter valid date.