freeoutdoorpt.com

Informed Consent and Liability Waiver Release For Participation in Exercise Program

This Agreement is between Ajantha Egodawatta (Freeoutdoorpt/ Instructor), The additional Instructors who may be conducting outdoor exercise sessions and the individual Whose name is signed below (referred to as the participant).

hereby agree to the following:

1. I am participating in outdoor Exercise sessions, offered by an instructor during which I will receive information and instruction about the exercise session. I recognize that it requires physical exertion that may be strenuous and may cause physical injury, I am fully aware of the risks and hazards involved and that it is MY RESPONSIBILITY to modify and movements to fit my limitations and level of conditioning.

2. I understand that is it my responsibility to consult with a physician prior to and regarding my participation in the exercise sessions. I represent and warrant that I am physically fit and I have no medical condition that would prevent my full participation in the Exercise Sessions.

3. In consideration of being permitted to participate in Exercise Sessions, I voluntarily and knowingly agree to assume full responsibility for any risks, injuries or damages, know or unknown, which I might incur as a result of participating in the program and acknowledge my informed consent to do so.

4. In further consideration of being permitted to participate in Exercise Sessions, I knowingly, voluntarily and expressively waive any claim I may have against the authorized instructor(s) and facilities for damages and injury, including death, resulting from the ordinary negligence of the Instructor, the Facility, its agents and employees, that I may sustain as a result of participating in the Exercise Sessions.

5. I, my heirs, spouse and legal representatives forever release, hold harmless, waive, discharge and covenant not to sue the instructor(s) or facilities for any injury or death caused by my voluntary participation in the Exercise Sessions.

6. This Agreement applies to personal injury or death arising from my participation at all locations where Exercise Sessions are instructed by Ajantha Egodawatta (or any Freeoutdoorpt instructors), including the facilities in and around the Facility (location) where the Exercise Sessions are taught and includes all claims for damages of any kind and for loss of property.

7. I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above. This agreement remains in effect for as long as I participate in Exercise Sessions.

Signature of Participant: *

Date *

Phone / Mobile *

Note: if the participant is not 18 years of age or older, he/she must have the consent of a parent or guardian.

as a parent or legal guardian of the above participant, hereby understand, agree to and assure responsibility for the above terms.

Signature of Parent or Legal Guardian:

Date

Do you allow me to contact you with information about classes and events?YesNo

Do you allow me to securely store your personal data?YesNo

Pre‐Activity Readiness Questionnaire (PAR‐Q)

This information will be kept confidential and only accessed by Freeoutdoorpt (Ajantha Egodawatta and any authorised instructors).

Please circle YES or NO to the following:

1. Has your doctor ever said that you have a heart condition?YesNo

2. Have you had chest pains, before, during or after performing physical activity?YesNo

3. Have you ever felt dizzy during or after exercise?YesNo

4. Is there a history of coronary disease in your immediate family?YesNo

5. Do you suffer from high or low blood pressure?YesNo

6. Do you suffer from high cholesterol?YesNo

7. Are you pregnant or have given birth within the last 6 months?YesNo

8. Have you had surgery recently?YesNo

Please specify

9. Do you have any chronic illness or physical limitations such as Asthma, diabetes?YesNo

Please specify

10. Do you have any existing injuries, bone/joint or orthopedic problems?YesNo

Please specify

11. Do you currently take any medications?YesNo

What is the medication for?

12. Any other factor which may affect your ability to participate in physical activity?YesNo

Please specify

If you answered YES to Q1‐12 you should consult your doctor before commencing activity. Tell your doctor what questions you answered yes to on this form.

Emergency Contact:

Please provide the name and number of someone who we can call in the event of an emergency (providing you have permission from that person to nominate):

Name

Number:

I confirm I have read and understood this PAR‐Q and have completed it to the best of my knowledge:

Name: *

Signature: *

Date: *

Email Address: *