Global training course form

Gender

Male Female Other

emergency contact number

In the past month, how many hours a week did you spend on physical activity?

In the past month, what were your most common forms of physical activity?

Are you currently suffering from an injury?

If yes, please specify its nature.

Has your doctor ever told you that you have a heart condition and that you should only participate in prescribed and approved physical activity?

Yes No

Do you feel pain in your chest when practising physical activity?

Yes No

In the past month, have you had chest pain when you were not doing physical activity?

Yes No

Do you lose your balance because of dizziness or do you ever lose consciousness?

Yes No

Do you have bones or joints problems (for example: back, knee or hip) that could be made worse by a modification of your level of participation in a physical activity?

Yes No

Are you currently taking prescribed drugs to control your blood pressure or treat a heart condition?

Yes No

Are you aware of any other physical factors, other than those mentioned above, which would prevent you from participating in a physical activity program, even if you want it?

Yes No

Additional information

I certify that the information indicated in this questionnaire is correct and complete.

Yes No

Acceptance of risks and disclaimer

I, undersigned, release Kin-Option from any liability for damage, injury or incident. I declare that I have the physical ability to participate in Kin-Option's training sessions. I am aware that participation in these sessions is a potentially dangerous activity. I agree not to participate in the training if I am not physically fit and well trained. I have chosen the most appropriate group level corresponding to my own capabilities to avoid overworking and effort beyond my expectations and abilities. I assume the risks associated with muscular and cardiovascular training, including falls or contact with other people or objects, and inclement weather. I agree that directors and leaders are not liable for any bodily injury, death or property loss, and I release the organizers of the outings and waive any recourse or claims in this matter.

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