Exercise Safety Questionnaire

17 Years & Under

Exercise Safety Questionnaire

  • Regular physical activity provides a wide range of immediate and long term health benefits. The benefits far outweigh the risks; however a very small number of people may be at risk when exercising. To help provide the highest level of safety, please complete the following form prior to your child taking part in any physical activity. This information is confidential and will be treated as per the amended Privacy Act 1988.
 

Emergency Contact Details - Parent or Guardian

 

Has your child been diagnosed with a medical condition?

 

Has your child experienced any abnormal episodes?

 

Has your child been diagnosed with psychological/behavioral disorders related to exercise?

 

Does your child have any muscle/bone or joint problems?

 

Does your child have any neuromuscular difficulties such as brain or spinal injuries?

 

Does your child have any sensory issues such as vision/hearing/speech or balance issues?

 

Does your child have any allergies of any kind?

 

Does your child currently take any medication?

 

Is there any other medical reason/condition which might prevent your child from participating in an exercise program?

 

Parent Release Consent:

  • I hereby acknowledge and give permission for my child to participate in the physical activities/program delivered by Health Mates Fitness Centre. The information stated, to the best of my knowledge, is correct and I will inform you of any changes of my child’s condition. I understand the benefit of physical activity outweigh the risks, however in a small number of people injuries may occur. I understand that in the case of an emergency my child will be treated as per the current policy of the facility. In consideration of the person named as the participant on this document being accepted to participate in any activity, I agree to release and indemnify the facility and facility operator and staff as follows: My child participates in these activities at their/ own risk and sole responsibility; I release, indemnify and hold harmless the facility operator, it’s servants and agents, from and against all and any actions or claims which may be made by me or on my behalf or by other parties for or in respect of arising out of injury, loss, damage or death caused to me or my property whether by neglect, breach of contract or in any way what so ever; and I agree that in the event that my child is injured or their property is lost or damaged, I will bring no claim, legal or otherwise, against the facility operator, it’s servants and agents, in respect of that injury, loss or damage. Before signing this document I have read and understand it and know how it affects my legal rights.
 

Verification