Name *

First Name

Last Name

Phone *

(###)

###

####

Has your doctor ever said that you have a heart condition, low blood pressure OR high blood pressure? *

Yes

No

Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity? *

Yes

No

Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise). *

Yes

No

Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? *

Yes

No

Are you currently taking prescribed medications for a chronic medical condition? *

Yes

No

Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active. *

Yes

No

Do you have diabetes mellitus or any other metabolic disorder? *

Yes

No

Have you ever suffered with shortness of breath at rest or with mild exercise? *

Yes

No

Is there any history of coronary heart disease within your family? *

Yes

No

Do you ever feel faint, have spells of dizziness or have ever lost consciousness? *

Yes

No

Are you or is there a possibility you might be pregnant? *

Yes

No

Do you know of any other reason why you should not participate in a programme of physical activity? *

Yes

No

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone Number *

(###)

###

####

By ticking the box below, you accept the waiver conditions outlined below *

Event Participation Waiver Acknowledgment of Risk and Release of Liability: - I understand that participating in this fitness event involves physical activity, which may carry a risk of injury. - I understand that this may include some outdoor running outside from the gym and that ‘Pyramid Performance’ or ‘Burgon Fitness’ are not liable should I injure myself during this run outside of the premises. - I confirm that I have answered the above PAR-Q honestly and to the best of my knowledge. - I acknowledge that I am responsible for monitoring my own condition during the event. - I give permission for photos and videos to be taken of me during the event and I accept these can be used online for promotional material. - I release the event organizers, staff, and affiliates from any liability for injury, illness, or damages that may occur as a result of my participation.

I agree to the above