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Health Form

Please fill out the below health form before attending class <3

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Are you suffering from a medical condition, illness, or injury?
Have you been hospitalized in the last 12 months?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Have you ever been told by a doctor that you have bone, joint, or muscle problems that could be made worse by physical activity?
Have you ever been told by a doctor that you have bone, joint, or muscle problems that could be made worse by physical activity?
Do you have a diagnosed illness that could be made worse by physical activity?
Is your doctor currently prescribing drugs for your blood pressure or heart condition?
Have you had recent surgery (in the last 6 months)?
Are you currently on any medications, either prescription or non-prescription, on a regular basis?
Do you have any allergies?
Do you know of any other reason why you should not do physical activity?

I hereby agree to the following:

1. That I am participating voluntarily in a Class/Workshop/Pole Hire/Studio Hire offered by Akila Pole Studio. I understand that pole dance/pole fitness requires physical exertion that may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved. I represent and warrant that I am physically fit and I have no medical condition that would prevent my full participation and I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating in the program.

2. I understand that I will receive physical assists or adjustments to enhance or correct my body posture during class by the instructor leading the class. I will take accountability for alerting the teacher and assistant of any injury or impairment in advance before class begins. 

3. I agree to self-determine my exertion through good judgment and to discontinue any activity that exceeds my personal limitations. 

4. I knowingly, voluntarily and expressly waive any claim I may have against Akila Pole Studio and any of its independent contractors (instructors) for injury or damages that I may sustain as a result of participating in the program.

 

5. I, my heirs or legal representatives forever release waive, discharge and covenant not to sue for any injury or accident caused by their negligence or other acts.

 

I have read the above release and waiver of liability and fully understand its contents.

Thanks for submitting!

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