Physical Activity Readiness Questionnaire (PAR-Q) and Health History Questionnaire (HHQ)

ASSUMPTION OF RISK, WAIVER AND RELEASE OF LIABILITY, AND INDEMNITY AGREEMENT

DECLARATIONS:

This Agreement is entered into between Excel Rocktown and the undersigned (“Client”). The provision of coaching services by Excel Rocktown to Client, and Client’s use of any premises, facilities or equipment are contingent upon this Agreement.

ASSUMPTION OF RISK:

You agree that if you engage in any physical exercise or activity, you do so at your own risk and assume the risk of any and all injury and/or damage you may suffer, whether while engaging in physical exercise or not. This includes injury or damage sustained while and/or resulting from using any premises or facility, or using any equipment, whether provided to you by Excel Rocktown or otherwise, including injuries or damages arising out of the negligence of Excel Rocktown, whether active or passive, or any of Excel Rocktown’s affiliates, employees, agents, representatives, successors, and assigns.

Your assumption of risk includes, but is not limited to, your use of any exercise equipment (mechanical or otherwise), sports fields, roads/trails (public or private), courts, or other areas, locker rooms, sidewalks, open bodies of water, swimming pools, swim flumes, parking lots, stairs, whirlpools, saunas, steam rooms, or other general areas of any facilities, or any equipment. You assume the risk of your participation in any activity, class, program, instruction, or event, including but not limited to weightlifting, walking, running (indoor or outdoor), cycling (indoor or outdoor), swimming (indoor or outdoor) or cross training activities. You agree that you are voluntarily participating in the aforementioned activities and assume all risk of injury, illness, damage, or loss to you or your property that might result, including, without limitation, any loss or theft of any personal property, whether arising out of the negligence of Excel Rocktown or otherwise.

RELEASE:

You agree on behalf of yourself (and all your personal representatives, heirs, executors, administrators, agents, and assigns) to release and discharge Excel Rocktown (and Coach’s affiliates, related entities, employees, agents, representatives, successors, and assigns) from any and all claims or causes of action (known or unknown) arising out of the negligence of Coach, whether active or passive, or any of Excel Rocktown’s affiliates, employees, agents, representatives, successors, and assigns.

This waiver and release of liability includes, without limitation, injuries which may occur as a result of (a) your use of any exercise equipment or facilities which may malfunction or break, (b) improper maintenance of any exercise equipment, premises or facilities, (c) negligent instruction or supervision, including coaching, (d) traveling to or from coaching session(s).

INDEMNIFICATION:

By execution of this agreement, you hereby agree to indemnify and hold harmless Excel Rocktown from any loss, liability, damage, or cost Excel Rocktown may incur due to the provision of coaching by Excel Rocktown to you.

ACKNOWLEDGMENTS:

You expressly agree that the foregoing release, waiver, assumption of risk and indemnity agreement is intended to be as broad and inclusive as permitted by the law in the State of Virginia and that if any portion thereof is held invalid, it is agreed that the balance of the waiver will continue in full legal force and effect. You acknowledge that Excel Rocktown offers a service to their clients encompassing the entire recreational, sporting and/or fitness spectrum. This release is not intended as an attempted release of claims of gross negligence or intentional acts.

You acknowledge that you have carefully read this waiver and release and fully understand that it is a release of liability, express assumption of risk and indemnity agreement. You are aware and agree that by executing this waiver and release, you are giving up your right to bring a legal action or assert a claim against Excel Rocktown for coach’s negligence, or for any defective product used while receiving coaching services from Excel Rocktown. You have read and voluntarily signed the waiver and release and further agree that no oral representations, statements, or inducement apart from the foregoing written agreement have been made.

PHYSICAL ACTIVITY READINESS QUESTIONNAIRE

Please answer each question honestly, use common sense as your guide.

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem (for example, back, knee, or hip) that could be made worse by a change in your physical activity?
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?

If you answered YES to one or more of the above questions, talk with your doctor BEFORE you start becoming much more physically active or BEFORE you start a coaching program. Tell your doctor about the PAR-Q and which questions you answered YES to.

You may be able to do any activity you want as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those which are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice.

If you answered NO to all the PAR-Q questions, you can be reasonably sure that you can start becoming more physically active and start a coaching program. It is also highly recommended that you have your blood pressure evaluated. If your reading is over 140/90, talk with your doctor before you start becoming more physically active or starting a coaching program.

PAR-Q developed by the Canadian Society for Exercise Physiology

HEALTH HISTORY QUESTIONNAIRE

I have answered the Health History Questionnaire questions accurately and completely. I understand that my medical history is a very important factor in the development of my coaching program. I understand that certain medical or physical conditions which are known to me, but that I do not disclose to my coach may result in serious injury to me. If any of the above conditions change, I will immediately inform my coach of those changes. I, knowingly and willingly, assume all risks of injury resulting from failure to disclose accurate, complete, and updated information in accordance with the attached questionnaire.

Name*

Email*

What are you cooking and craving?*

Age, Height, Weight*

Emergency Contact and Number*

Personal Physician and Number*

Have you ever had a definite or suspected heart attack or stroke?*

Have you ever had coronary bypass surgery or any other type of heart surgery?

Do you have any other cardiovascular or pulmonary (lung) disease (other than asthma, allergies, or mitral valve prolapse)*

Do you have a history of: diabetes, thyroid, kidney, liver disease?*

Have you ever been told by a health professional that you have had an abnormal resting or exercise electrocardiogram (EKG)?*

If you answered YES to any of the above questions, please describe.

Do you currently have any of the following:

Pain or discomfort in the chest or surrounding area that occurs when you engage in physical activity? Shortness of breath Unexplained dizziness or fainting Difficulty breathing at night except in upright position Swelling of ankles Heart palpitations Pain in the legs that causes you to stop walking Known heart murmor

Have you discussed any of the above with your personal physician?*

Are you pregnant or is it likely that you could be pregnant at this time?*

Have you had surgery or been diagnosed with any disease in the past 3 months?*

Have you had high blood cholesterol or abnormal lipids within the past 12 months or are you taking medication to control your lipids?*

Do you currently smoke cigarettes or have quit within the past 6 months?*

Have your father or brothers had heart disease prior to age 55 OR mother or sisters prior to age 65?*

Within the past 12 months, has a health professional told you that you have high blood pressure (systolic >140 OR diastolic >90)*

Currently, do you have high blood pressure or within the past 12 months, have you taken any medicines to control your blood pressure?*

Have you ever been told by a health professional that you have a fasting blood glucose greater than or equal to 110 mg/dl?*

If you have answered Yes to any of the above questions, please describe.*

Describe your regular physical activity or exercise program: (type, frequency: days per week, duration: hours, intensity: low, moderate, high)*

Are you currently under any treatment for any blood clots?*

Do you have problems with bones, joints, or muscles that may be aggravated with exercise?*

Do you have any back/neck problems?*

Have you been told by a health professional that you should not exercise?*

Are you currently being treated for any other medical condition by a physician?*

Are there any other conditions (mitral valve prolapse, epilepsy, history of rheumatic fever, asthma, cancer, anemia, hepatitis, etc.) that may hinder your ability to exercise?*

During the past six months, have you experienced any unexplained weight loss or gain (greater than ten pounds for no known reason)?*

If you have answered YES to the above questions, please describe:

Please list below all prescription and over-thecounter medications you are currently taking:*

Are there any medicines that your physician has prescribed to you in the past 12 months which you are currently not taking? Please list, if so.

I have read the disclosure statement and waive Excel Rocktown of liability forthwith. (Sign by typing your name and date)