Child's Par-Q

CHILD'S PAR-Q FORM

Child’s Name:

Parent/Guardian’s Name (who will be collecting child):

Address:

Street AddressCityPostal / Zip Code

Child's Date of Birth:

Child's Current Age:

EMERGENCY CONTACT NUMBERS:

Mobile Number:

1. Name & relationship to Child:

Home Number:

2. Name & relationship to Child:

Work Number:

3. Name & relationship to Child:

How Did you hear about this class:

HEALTH QUESTIONS:

Does your child have or ever experienced the following?:

High or low Blood Pressure

Yes

Elevated Blood Cholesterol

Yes

Diabetes

Yes

Chest Pain brought on by physical exertion

Yes

Childhood Epilepsy

Yes

Dizziness or Fainting

Yes

A bone, joint or muscular problem or arthrisitis

Yes

Asthma or other respiratory problems

Yes

Any sustained injuries or illnesses

Yes

Any allergies

Yes

Is your child taking any medication

Yes

Has your doctor ever advised your child not to exercise

Yes

Is there any reason not mentioned above why any type of physical activity may not be suitable for your child?

Yes

If you have answered yes to any of the questions please give full details here:

Any special dietary needs for your child?:

Do you give your consent for plasters to be used on your child?

Yes

In submitting this form, I the parent/guardian of the afore mentioned 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 understand that my child is responsible for monitoring him or herself throughout any activity, and should unusual symptoms occur, they would cease participation and inform the instructor.

I understand that if my child is below the age of six years that I the parent/guardian am responsible for monitoring them within their activities

In the event that medical clearance must be obtained prior to my child’s participation in an exercise session, I agree to contact their GP and obtain written permission prior the commencement of the exercise activity and that this permission to be given to the instructor.

I understand that if my child fails to behave in a manner that is polite and social, he or she could be suspended from that particular activity. During the sessions, we will be using the time out method...

The child is given a verbal warning if this needs to be given again the child is asked to sit out for 3 minutes and is then expected to apologies to come back into the session.

If the child continually misbehaves they may not be able to continue in the club.

I give permission for my child to be in a photo/video for Fitjoy promotion that may be used in a poster or Fitjoy website?

Yes

Name of Parent or Guardian:

Date:

I agree the information above is true and correct.

Agree