Disclaimer form.

The Pole Vault

Disclaimer form

 

Name …………………………………………………………

Date of Birth …………………………….

Address……………………………………………………………………………………………………………………………………………………………………………………………..

Telephone number…………………………………………..

Email address………………………………………………..

 

HEALTH QUESTIONS

Have you ever suffered from the following complaints?

Heart conditions or chest pain?

High or low blood pressure?

Faintness or dizzy spells?

Asthma?

Diabetes?

Nickel allergy?

Are you pregnant?

Have you had any operations in the past year?

Any recent injuries?

Bone or joint problems?

Body issues such as EDS/Fibromyalgia

Prescribed medicines

Other medical condition not listed

 

Please provide details of your condition and any medication you are taking …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

If you have answered YES to any of the above, please seek medical advice from your GP before participating.

Polefit is a physically demanding sport and can result in bruising or friction burn as your skin gets used to it. Your muscles may feel sore or achy for a few days. We strongly recommend you always participate in the warm up and cool down to prevent muscle damage.

Polefit is a dangerous sport and by signing this form, you show understanding that there is a risk of personal injury.

Please notify your instructor if you have any recent injuries, illnesses or medical conditions, or if there are parts of the sessions you cannot physically participate in. All information is private and confidential. If you feel excessive pain or discomfort during the session, notify the instructor immediately.

All instructors are first aid trained.

Please DO NOT DRINK ALCOHOL or TAKE DRUGS prior to a polefit lesson. If you are intoxicated, you WILL be asked to leave and no refund will be issued.

During some moves, the instructor may need to make physical contact with you in the form of spotting to give guidance, support or security. If you are not comfortable with this, please either tell your instructor or make a note on this form. Please understand that certain moves are not safe without a spotter while you are learning them and may result in injury.

 

Name (print)…………………………………………….

Signature………………………………………………..

Date ……………………………………

 

Emergency contact details

Emergency contact name……………………………………………….

Relationship to you……………………………………………

Emergency contact number……………………………………………..

Photo release form

Photo release form

 

“I hereby give my consent for The Pole Vault to use my photograph and likeness in all forms and media for advertising, trade and any other lawful purposes.”

 

Signed

 

Print name

 

 

Date:

 

If you’re signing on behalf of anyone under the age of 18.

 

 “I attest that I am the parent or guardian of the child(ren). I have read this release and approve of its terms.”

 

Signed

 

 

Print name

 

 

Name of child                                                                                    Age of child

 

 

Date:

Pole on The Road , Bringing the Fun to you !

Email: thepolevaultstudio@outlook.com  Contact Tel : 07821758048 

 

Mobile Pole Classes , Group classes , Private Classes , Parties .