Emergency Contact

Regular physical activity can be fun and exhilarating and on the whole is usually safe and enjoyable. To ensure that your time with us is spent enjoying the benefits of physical activity we must verify that you are in sound physical condition and that you have checked with your doctor that you are able to participate in any form of exercise. By completing the questionnaire below we will be able to monitor your readiness to participate in physical activity.

If you answer YES to any of the questions you must consult your doctor to ensure that it is safe for you to start an exercise programme with us. If you answer NO to all of the questions then we can be reasonably confident that it is safe for you to undertake an exercise programme with us.

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?*

YesNo

When you do any physical activity do you feel pain in your chest?*

YesNo

Have you ever felt faint or had spells of dizziness?*

YesNo

Do you have any bone or joint problems that could be made worse by a change in your physical activity?*

YesNo

Have you ever suffered from high blood pressure?*

YesNo

Are you currently on any medication that could affect your health by a change in your physical activity?*

YesNo

Are you pregnant or have you had a baby in the last 6 months*

YesNo

Are you over 70 years of age?*

YesNo

Do you know of any reason why you should not exercise or increase your physical activity? (If yes, please give details below)*

YesNo

Full Name*

First NameLast Name

Date of birth*

Address*

E-mail*

Phone*

Full Name*

First NameLast Name

Phone*

I have completed the above questionnaire honestly and to the best of my knowledge. I accept that I undertake any activities with Richard Williams and Scorpion Training at my own risk. If I have answered yes to any of the questions I have consulted my doctor and gained their agreement to me undertaking a physical activity programme. If my health changes at anytime so that I would answer yes to any of the above then I will cease exercising and consult my doctor.

Agreement*

I agree

Disclaimer I, the undersigned, being aware of my own health and physical condition and having knowledge that my participation in any exercise programme may be injurious to my health, am voluntarily participating in physical activity with Richard Williams and Scorpion Training. Having such knowledge, I hereby release (Richard Williams and Scorpion Training), their representatives and agents from liability for accidental injury or illness which I may incur as a result of participating in said physical activity. I hereby assume all risks connected there with and consent to participate in said program. I agree to disclose any physical limitations, disabilities, ailments or impairments which may affect my ability to participate in said program..

Agreement*

I agree