The Beach Wellness PARQ

First Name*

Last Name*

Telephone

Email*

Date of birth*

Gender*

House Name / Number*

Street*

Town / City*

Postcode*

Name of emergency contact*

Emergency contacts phone number*

GP Surgery Name*

How did you find out about The Beach Wellness?

Please read the following questions carefully and answer them to the best of your knowledge. They are intended to identify any health concerns related to exercise and to determine whether you should consult your GP before starting new exercise.

If you answer 'Yes' to any question, are currently inactive, unused to physical activity, or 65+ years of age, you should consult your doctor to confirm it is safe for you to become physically active at this time and in your current state of health.

Do you have or have you ever been diagnosed with a heart condition?*

Do you ever feel pain in your chest?*

Do you ever feel dizzy or lose consciousness?*

Do you suffer or have you ever suffered from diabetes?*

Is your doctor currently prescribing drugs for your blood pressure or heart condition?*

Have you ever been informed that your blood cholesterol is high?*

Do you have any form of muscle, joint or back injury, or a diagnosed joint condition?*

Do you suffer or have you ever suffered from asthma, COPD, bronchitis, or any other breathing difficulty?*

Have you ever suffered a stroke? (CVA or TIA)*

Do you suffer or have you ever suffered from epilepsy?*

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

If you answered 'Yes' to any of the above questions, please provide full details (please specify condition and detail all medication you are currently taking)

I have read, understood & accurately completed this questionnaire. I can confirm that I am voluntarily engaging in an acceptable level of exercise, & my participation involves a risk of injury. This PARQ becomes invalid should your condition change

Signature*

Date*

Please confirm you have read and agreed to the Privacy Policy & Code of Conduct statements (found below)*

Security Check*

What is 1 plus 1?

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Safeguarding

Somerset Activity & Sports Partnership (SASP) is committed to providing safe, enjoyable activities and sporting opportunities for all.

Your safety and well-being are very important to us. If any part of the activities or sessions make you feel uncomfortable, or if you have concerns about your safety or the safety of others, please speak to a member of The Beach Wellness team immediately, or contact the SASP Safeguarding team at safeguarding@sasp.co.uk/01823 653990. We are committed to providing a safe and supportive environment for everyone.

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GDPR Statement -The Beach Wellness

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Code of Conduct - The Beach Wellness

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GOV17 - Privacy Notice - Clients

The Beach Wellness PARQ

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