PAR-Q

Full Name *

Date of Birth *

Gender and Pronouns *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone Number *

Emergency Contact Name *

First

Last

Emergency Contact Number *

2nd Emergency Contact Name *

First

Last

2nd Emergency Contact Number *

Do you have any injuries Rosie Rainbow or other instructors should be aware of or that may prevent you from taking part? Do you have any injuries that may be aggravated by taking part? *

Yes No

Has your doctor or other health care professional advised you not to participate in physical activity? *

Yes No

Do you have any illness or disability which would limit your taking part in physical activity? *

Yes No

Do you have any allergies? *

Yes No

Are you on any medications? *

Yes No

Do you have any history of high / low blood pressure, eye problems (e.g. detached retina), stroke, cholesterol problems, heart disease or vertigo? *

Yes No

Do you suffer from dizziness or shortness of breath when exercising? *

Yes No

Do you have any transmittable or blood diseases? *

Yes No

Do you have any back, neck or joint problems? *

Yes No

Have you had any operations within the last five years? *

Yes No

Are you currently or have you recently been pregnant? *

Yes No

Do you know of any other reason why you should not take part in physical activity? *

Yes No

If you have answered "Yes" to any of these questions please provide details below or write "N/A" *

Standard informed consent, please tick to confirm you have read and accepted each statement.* *

Wherever possible, we will accommodate any individual because Circus should be accessible for everybody. Adjustments may need to be made, medical advice sought or a doctor's note provided if you have answered "yes" to any of the questions on the medical questionnaire. We therefore reserve the right to defer any student to seek medical guidance before participating in our class. Circus skills can be physically challenging. Minor bumps, scraps, bruises and strains can be common. Whilst we seek to mitigate risk, unfortunately due to the nature of the activity it is more of an inevitability than a possibility. Please wear the appropriate clothing for activities. Students must work within their own capabilities and listen to instruction at all times. Any injuries must be disclosed to the instructor. The instructor will from time to time need to touch you for spotting, posture, alignment, correction, positioning and safety purposes. Please indicate in the "any other information" box (above) and ensure you discuss with the instructor if you feel you have any additional sensory or safety needs regarding physical touch. Please ensure you are on time for class and stay until the end of the session in order to benefit from the warm up and cool down which are essential to avoid muscle strains and stiffness. If you would like to see risk assessment, first aid certification or insurances please ask. You agree to take full responsibility for your actions during all parts of training. You understand that you may receive some bruising, muscle soreness, potential broken bones and chafing.In particular aerial activities have a risk of falling from height, burns, bruising and grazes. By taking part in a class you understand that you may receive injuries which could result in death. You assume complete responsibility and liability for those risks and for the injuries that may occur as a result of these risks, even if injuries occur in a manner that is not foreseeable at the time you submit this agreement. You understand that it is your responsibility to communicate any physical and / or mental impairments you may have before a class to enable instructors to best support you or direct you to a class more suitable for your needs. You agree to cease participation if you feel unwell and will work at your own level throughout the class. By submitting this form you are confirming that you have answered all questions to the best of your knowledge and have read and understood all the information above. You are aware of the risks involved in the training, take part at your own risk and waive the instructor of responsibility in the event of an accident. Additionally, by submitting this form you confirm that you are over 16 years of age. I confirm that I have disclosed all medical conditions to Rosie Rainbow Circus and any instructors working for her and that, where relevant, I will carry personal medical equipment at all times (e.g. epi-pen, inhalers, etc...) *

I give permission for photographs and videos to be taken and published in the private Facebook group for members of my class & their families *

Yes No

I give permission for images of me to appear in promotional photography / video clips of Rosie Rainbow Circus / Rainbow Circus CIC sessions. This material may be used on the website, Facebook, Instagram or on other promotional media *

Yes No

I would like Rosie Rainbow Circus or Rainbow Circus CIC to tag me in these images. *

Yes No

Please confirm that you agree to be added to Rainbow Circus CIC's newsletter mailing list in relation to offers / events / information *Choose One *

Yes No

Submit

YOUR CART

Participant questionnaires

Rainbow Circus CIC 16+ Student PAR-Q

Rainbow Circus CIC Under 16 PAR-Q