PAR-Q+€¦ · 2a. Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and neck? 2b. Are you currently

YES NOPlease read the 7 questions below carefully and answer each one honestly: check YES or NO.

1) Has your doctor ever said that you have a heart condition OR high blood pressure ?

4) Have you ever been diagnosed with another chronic medical condition (other than heart diseaseor high blood pressure)? PLEASE LIST CONDITION(S) HERE:

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

7) Has your doctor ever said that you should only do medically supervised physical activity?

2) Do you feel pain in your chest at rest, during your daily activities of living, OR when you dophysical activity?

3) 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).

6) 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 physicallyactive? Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active. PLEASE LIST CONDITION(S) HERE:

GENERAL HEALTH QUESTIONS

If you answered NO to all of the questions above, you are cleared for physical activity.Go to Page 4 to sign the PARTICIPANT DECLARATION. You do not need to complete Pages 2 and 3.

If you answered YES to one or more of the questions above, COMPLETE PAGES 2 AND 3.

Delay becoming more active if:You have a temporary illness such as a cold or fever; it is best to wait until you feel better.

You are pregnant - talk to your health care practitioner, your physician, a quali�ed exercise professional, and/orcomplete the ePARmed-X+ at www.eparmedx.com before becoming more physically active.

Your health changes - answer the questions on Pages 2 and 3 of this document and/or talk to your doctor or a quali�ed exercise professional before continuing with any physical activity program.

Copyright © 2015 PAR-Q+ Collaboration 1 / 401-01-2015

PLEASE LIST CONDITION(S) AND MEDICATIONS HERE:

Start becoming much more physically active – start slowly and build up gradually.

Follow International Physical Activity Guidelines for your age (www.who.int/dietphysicalactivity/en/).

You may take part in a health and �tness appraisal.

If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal e�ort exercise, consult a quali�ed exercise professional before engaging in this intensity of exercise.

If you have any further questions, contact a quali�ed exercise professional.

PAR-Q+The Physical Activity Readiness Questionnaire for Everyone

The health benefits of regular physical activity are clear; more people should engage in physical activity every day of the week. Participating in physical activity is very safe for MOST people. This questionnaire will tell you whether it is necessary for you to seek further advice from your doctor OR a qualified exercise professional before becoming more physically active.

1. Do you have Arthritis, Osteoporosis, or Back Problems?

1a. Do you have di�culty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

1b. Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer, displaced vertebra (e.g., spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)?

1c. Have you had steroid injections or taken steroid tablets regularly for more than 3 months?

If the above condition(s) is/are present, answer questions 1a-1c If NO go to question 2

2. Do you have Cancer of any kind?If the above condition(s) is/are present, answer questions 2a-2b

3. Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart RhythmIf the above condition(s) is/are present, answer questions 3a-3d

If the above condition(s) is/are present, answer questions 5a-5e

5. Do you have any Metabolic Conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes

If NO go to question 3



4. Do you have High Blood Pressure?If the above condition(s) is/are present, answer questions 4a-4b


4b. Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication?(Answer YES if you do not know your resting blood pressure)


2a. Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer ofplasma cells), head, and neck?

2b. Are you currently receiving cancer therapy (such as chemotheraphy or radiotherapy)?


3b. Do you have an irregular heart beat that requires medical management?(e.g., atrial �brillation, premature ventricular contraction)

3c. Do you have chronic heart failure?

3d. Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months?

5a. Do you often have di�culty controlling your blood sugar levels with foods, medications, or other physician- prescribed therapies?

5b. Do you often su�er from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or during activities of daily living? Signs of hypoglycemia may include shakiness, nervousness, unusual irritability,abnormal sweating, dizziness or light-headedness, mental confusion, di�culty speaking, weakness, or sleepiness.

5c. Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications a�ecting your eyes, kidneys, OR the sensation in your toes and feet?

5d. Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, orliver problems)?

5e. Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

PAR-Q+FOLLOW-UP QUESTIONS ABOUT YOUR MEDICAL CONDITION(S)

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

Copyright © 2015 PAR-Q+ Collaboration 2 / 401-01-2015

If the above condition(s) is/are present, answer questions 7a-7d

If the above condition(s) is/are present, answer questions 8a-8c

If the above condition(s) is/are present, answer questions 9a-9c

If you have other medical conditions, answer questions 10a-10c




If NO read the Page 4 recommendations

PAR-Q+

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

Copyright © 2015 PAR-Q+ Collaboration 3 / 4

GO to Page 4 for recommendations about your current medical condition(s) and sign the PARTICIPANT DECLARATION.

7. Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary HighBlood Pressure


7b. Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?

7c. If asthmatic, do you currently have symptoms of chest tightness, wheezing, laboured breathing, consistent cough (more than 2 days/week), or have you used your rescue medication more than twice in the last week?

7d. Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?

8. Do you have a Spinal Cord Injury? This includes Tetraplegia and Paraplegia


8b. Do you commonly exhibit low resting blood pressure signi�cant enough to cause dizziness, light-headedness, and/or fainting?

8c. Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysre�exia)?

9. Have you had a Stroke? This includes Transient Ischemic Attack (TIA) or Cerebrovascular Event


9b. Do you have any impairment in walking or mobility?

9c. Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?

10. Do you have any other medical condition not listed above or do you have two or more medical conditions?

10a. Have you experienced a blackout, fainted, or lost consciousness as a result of a head injury within the last 12 months OR have you had a diagnosed concussion within the last 12 months?

10b. Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)?

10c. Do you currently live with two or more medical conditions?

PLEASE LIST YOUR MEDICAL CONDITION(S) AND ANY RELATED MEDICATIONS HERE:

01-01-2015

6. Do you have any Mental Health Problems or Learning Di�culties? This includes Alzheimer’s, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome

If the above condition(s) is/are present, answer questions 6a-6b If NO go to question 7


6b. Do you ALSO have back problems a�ecting nerves or muscles?

YES NO

YES NO

PARTICIPANT DECLARATION

NAME ____________________________________________________

SIGNATURE ________________________________________________

SIGNATURE OF PARENT/GUARDIAN/CARE PROVIDER ____________________________________________________________________

DATE _________________________________________

WITNESS ______________________________________

Copyright © 2015 PAR-Q+ Collaboration 4 / 4

For more information, please contact

Key References

www.Divine SportsTraining.com [email protected]

1. Jamnik VK, Warburton DER, Makarski J, McKenzie DC, Shephard RJ, Stone J, and Gledhill N. Enhancing the e�ectiveness of clearance for physical activity participation; background and overall process. APNM 36(S1):S3-S13, 2011.2. Warburton DER, Gledhill N, Jamnik VK, Bredin SSD, McKenzie DC, Stone J, Charlesworth S, and Shephard RJ. Evidence-based risk assessment and recommendations for physical activity clearance; Consensus Document. APNM36(S1):S266-s298, 2011.

Citation for PAR-Q+Warburton DER, Jamnik VK, Bredin SSD, and Gledhill N on behalf of the PAR-Q+ Collaboration.The Physical Activity Readiness Questionnaire for Everyone (PAR-Q+) and Electronic Physical ActivityReadiness Medical Examination (ePARmed-X+). Health & Fitness Journal of Canada 4(2):3-23, 2011.

You should seek further information before becoming more physically active or engaging in a �tness appraisal. You should complete the specially designed online screening and exercise recommendations program - the ePARmed-X+ at www.eparmedx.com and/or visit a quali�ed exercise professional to work through the ePARmed-X+ and for further information.

PAR-Q+If you answered NO to all of the follow-up questions about your medical condition, you are ready to become more physically active - sign the PARTICIPANT DECLARATION below:

It is advised that you consult a quali�ed exercise professional to help you develop a safe and e�ective physical activity plan to meet your health needs.

You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate intensity exercise, 3-5 days per week including aerobic and muscle strengthening exercises.

As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week.

If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal e�ort exercise, consult aquali�ed exercise professional before engaging in this intensity of exercise.

If you answered YES to one or more of the follow-up questions about your medical condition:

All persons who have completed the PAR-Q+ please read and sign the declaration below.

If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care provider must also sign this form.

I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that a Trustee (such as my employer, community/�tness centre, health care provider, or other designate) may retain a copy of this form for their records. In these instances, the Trustee will be required to adhere to local, national, and international guidelines regarding the storage of personal health information ensuring that the Trustee maintains the privacy of the information and does not misuse or wrongfully disclose such information.

Delay becoming more active if:

You have a temporary illness such as a cold or fever; it is best to wait until you feel better.

You are pregnant - talk to your health care practitioner, your physician, a quali�ed exercise professional, and/or complete the ePARmed-X+ at www.eparmedx.com before becoming more physically active.

Your health changes - talk to your doctor or quali�ed exercise professional before continuing with any physical activity program.

You are encouraged to photocopy the PAR-Q+. You must use the entire questionnaire and NO changes are permitted.The authors, the PAR-Q+ Collaboration, partner organizations, and their agents assume no liability for persons who undertake physical activity and/or make use of the PAR-Q+ or ePARmed-X+. If in doubt after completing the questionnaire, consult your doctor prior to physical activity.

The PAR-Q+ was created using the evidence-based AGREE process (1) by the PAR-Q+ Collaboration chaired by Dr. Darren E. R. Warburton with Dr. Norman Gledhill, Dr. Veronica Jamnik, and Dr. Donald C. McKenzie (2). Production of this document has been made possible through �nancial contributions from the Public Health Agency of Canada and the BC Ministry of Health Services. The views expressed herein do not necessarily represent the views of the Public Health Agency of Canada or the BC Ministry of Health Services.

01-01-2015

Mission Statement

Success is always the starting point of every venture. As such, no one enters an endeavor

without a plan to succeed. Success will come with time but out of failure and struggle comes

strength, unity and trust. The capacities to reach the end goals of success are predicated upon the

inevitable struggle of failure. It is the mission of this Training Program to educate and empower

confidence, commitment and integrity, so that one can live a productive and successful

tomorrow.

The successful participant will exhibit the appropriate fundamentals and physical

condition to be able to excel in the sport of their choosing or achieve their optimal fitness.

Respect encompasses being professional and understanding the correct time to speak or to listen.

Also it entails having a teachable spirit and a desire to become Great. Discipline is having trust

and believing the professional is doing everything possible for the participants to achieve the end

goal.

WAIVER AND RELEASE OF LIABILITY In consideration of the risk of injury while participating in physical activity training regimen (the

"Activity"), and as consideration for the right to participate in the Activity, I hereby, for myself,

my heirs, executors, administrators, assigns, or personal representatives, knowingly and

voluntarily enter into this waiver and release of liability and hereby waive any and all rights,

claims or causes of action of any kind whatsoever arising out of my participation in the Activity,

and do hereby release and forever discharge Divine Sports Training LLC, located at PO box

144453, 251 Valencia ave, Miami, Fl 33134-5905, its consultants, officers, directors, agents and

employees, for any physical or psychological injury, including but not limited to illness,

paralysis, death, damages, economical or emotional loss, that I may suffer as a direct result of my

participation in the aforementioned Activity, including traveling to and from an event related to

this Activity.

I am voluntarily participating in the aforementioned Activity and I am participating in the

Activity entirely at my own risk. I am aware of the risks associated with traveling to and from as

well as participating in this Activity, which may include, but is not limited to, physical or

psychological injury, pain, suffering, illness, disfigurement, temporary or permanent disability

(including paralysis), economic or emotional loss, and death. I understand that these injuries

or outcomes may arise from my own or others' negligence, conditions related to travel, or

the condition of the Activity location(s). Nonetheless, I assume all related risks, both known

or unknown to me, of my participation in this Activity, including travel to, from and

during this Activity.

To the fullest extent permitted by law, I shall indemnify and hold Divine Sports Training, LLC,

its consultants, and its officers, directors, agents and employees from and against claims,

damages, losses or expenses, including but not limited to attorneys’ fees, to the extent arising out

of or resulting from any negligent acts, intentional acts or omissions under this

Agreement, EVEN THOUGH CAUSED OR ALLEGED TO BE CAUSED BY THE SOLE

JOINT, COMPARATIVE, OR CONCURRENT NEGLIGENCE OR FAULT OF DIVINE

SPORTS TRAINING, LLC OR ITS AGENTS AND EVEN THOUGH ANY SUCH

CLAIM, CAUSE OF ACTION, OR SUIT IS BASED UPON OR ALLEGED TO BE

BASED UPON THE STRICT LIABILITY OF DIVINE SPORTS TRAINING, LLC. THIS

INDEMNITY PROVISION IS INTENDED TO INDEMNIFY DIVINE SPORTS

TRAINING, LLC AND ITS AGENTS AGAINST THE CONSEQUENCES OF ITS OWN

NEGLIGENCE OR FAULT AS PROVIDED ABOVE WHEN DIVINE SPORTS

TRAINING, LLC IS SOLELY, JOINTLY, COMPARATIVELY, OR CONCURRENTLY

NEGLIGENT WITH YOU. This indemnity provision shall survive termination or expiration of

this Agreement. Such obligation shall not be construed to negate, abridge, or reduce other rights

or obligations or indemnity under the law.

I acknowledge that Divine Sports Training, its consultants, officers, directors, agents and

employees are not responsible for errors, omissions, acts or failures to act of any party or entity

conducting a specific event or activity on behalf of Divine Sports Training.

I understand, recognize, and acknowledge that participating in any sport or physical activity can

be dangerous and can involve many risks of serious injury and/or death. I acknowledge that this

Activity may involve a test of a person's physical and mental limits and may carry with it the

potential for death, serious injury, and property loss. I understand that the dangers and risks

include, but are not limited to, serious neck and spinal injuries which may result in complete or

partial paralysis, brain damage, serious injury to internal organs, bones, and other parts of the

skeletal/muscular system, and other serious physical and other injuries. I understand that the

dangers and risks also include other impairment of health and well-being, including impairment

affecting the future ability to earn a living, engage in educational, occupational, social, and

recreational activities, and generally enjoy life. The risks may include, but are not limited to,

those caused by terrain, facilities, temperature, weather, lack of hydration, condition of

participants, equipment, vehicular traffic and actions of others, including but not limited to,

participants, volunteers, spectators, coaches, event officials and event monitors, and/or producers

of the event. I am voluntarily participating in this Activity and using Divine Sports Training,

LLC’s equipment and utilizing their services with knowledge of the danger and risks involved. I

hereby assume and accept any and all risks associated with my participation in the Activity.

I acknowledge that I have carefully read this "waiver and release" and fully understand that it is a

release of liability. I expressly agree to release and discharge Divine Sports Training, LLC, its

consultants, and its officers, directors, agents and employees, from any and all claims or causes

of action and I agree to voluntarily give up or waive any right that I otherwise have to bring a

legal action against Divine Sports Training, LLC, for personal injury or property damage.

In the event that I should require medical care or treatment, I agree to be financially responsible

for any costs incurred as a result of such treatment. I am aware and understand that I should carry

my own health insurance.

In the event that any damage to equipment or facilities occurs as a result of my or my family's

willful actions, neglect or recklessness, I acknowledge and agree to be held liable for any and all

costs associated with any actions of neglect or recklessness.

This Waiver and Release was entered into at arm's-length, without duress or coercion, and is to

be interpreted as an agreement between two parties of equal bargaining strength. Both the

Participant, __________________________, and Divine Sports Training, LLC agree that this

Waiver and Release is clear and unambiguous as to its terms, and that no other evidence will be

used or admitted to alter or explain the terms of this Waiver and Release, but that it will be

interpreted based on the language in accordance with the purposes for which it is entered into.

In the event that any provision contained within this Release of Liability shall be deemed to be

severable or invalid, or if any term, condition, phrase or portion of this agreement shall be

determined to be unlawful or otherwise unenforceable, the remainder of this agreement shall

remain in full force and effect, so long as the clause severed does not affect the intent of the

parties. If a court should find that any provision of this agreement to be invalid or unenforceable,

but that by limiting said provision it would become valid and enforceable, then said provision

shall be deemed to be written, construed and enforced as so limited.

The terms and conditions set forth herein are governed by, and are to be construed in accordance

with, the laws of the State of Florida. If any action at law or in equity, including an action for

declaratory relief, is brought to enforce or interpret any term or condition or to enforce any right

and/or legal remedy, such action must be brought in a State or Federal court in the State of

Florida with a venue in the County of Miami-Dade. Divine Sports Training, LLC reserves the

right to move any and all disputes to binding arbitration. By making payment, you agree to cover

the cost of any and all litigation or any other legal costs Divine Sports Training, LLC may incur

due to any legal action taken by you. You agree that you will be responsible for your own fees

and costs regardless of whether or not you are prevailing party in any lawsuit against Divine

Sports Training, LLC, its consultants, and its officers, directors, agents and employees.

In the event of an emergency, please contact the following person(s) in the order presented:

Emergency Contact Contact Relationship Contact Telephone

I, the undersigned participant, affirm that I am of the age of 18 years or older, and that I am

freely signing this agreement. I certify that I have read this agreement, that I fully understand its

content and that this release cannot be modified orally. I am aware that this is a release of

liability and a contract and that I am signing it of my own free will.

Participant's Name:

Participant's Address:

Signature:

Date:

PARENT / GUARDIAN WAIVER FOR MINORS

In the event that the participant is under the age of consent (18 years of age), then this release

must be signed by a parent or guardian, as follows:

I hereby certify that I am the parent or guardian of ____________________________, named

above, and do hereby give my consent without reservation to the foregoing on behalf of this

individual.

Parent / Guardian Name:

Relationship to Minor:

Signature:

Date:

Cancellation Policy

A 24-hour courtesy notice for cancellation of appointment is kindly requested should the

necessity arise. Failure to adhere to this policy will result in loss of session.

Participant's Name:

Participant's Address:

Signature:

Date:

Documents

PAR-Q+€¦ · 2a. Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and neck? 2b. Are you currently