Childs Name *

First Name

Last Name

Parent/Guardian Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name *

First Name

Last Name

Preferred Class Day/s *

Monday

Wednesday

Thursday

Children’s Physical Activity Readiness Questionnaire (PAR-Q) Screening Form *

The purpose of this form is to provide us with specific details of your child’s medical history and general health information so that we can avoid any risk of injury or illness. Completion and submission of this questionnaire is mandatory before your child is permitted to participate in any Fitletica program. Has your child ever experienced any of the following. Please tick if applicable:

Chest pains brought on by physical exertion

Heart problems

Seizures, dizziness or fainting

Diagnosed psychological/behavioural disorders related to exercise

Neuromuscular difficulties

Muscle, bone or joint problems

Asthma or other respiratory problems

Diabetes

Sensory issues such as vision, hearing, speech, balance

Allergies

Medications - any known side effects

Other medical reason/condition which might prevent your child from participating in physical activity

No known medical conditions/concerns

Terms and Conditions/Consent *

Please click link on bottom of page for full Terms and Conditions.

I have read and accept the Terms and Conditions

I give permission for my child to commence your physical activity program.