Participant Activity Readiness Questionnaire

Name(Required)

First Last

Date of birth(Required)

Email(Required)

Phone(Required)

Name of class/es attending (select all that apply):(Required)

Zumba

Yoga

Tap Dancing

Pilates

Chance to Dance

Dance Blast

Body Conditioning

Boogie with Baby

Emergency contact name(Required)

First Last

Emergency contact number(Required)

Do you have any medical conditions?(Required)

Are you pregnant or have given birth within the last 6 weeks?(Required)

Are you taking any prescribed medicines? (Please ensure you have angina/asthma medication with you)(Required)

Do you have any allergies?(Required)

Is there any other reason you are aware of that means you should not participate in physical activity?(Required)

If you have answered YES to any of the above, please provide further details below.

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