PC-ONLINE-PARQ-2019

First name

Surname

Date of Birth (dd/mm/yy)

Age

Email Address

Your Contact Number

Please read the following questions carefully and answer honestly for each question.

1. Has your Doctor ever said that you have a heart condition or you should only do physical activity recommended by a Doctor?

YES NO

2. Do you feel pain in your chest when you do physical activity?

YES NO

3. In the past month have you had pain in your chest when not doing physical activity?

YES NO

4. Do you lose your balance because of dizziness, or do you ever lose consciousness?

YES NO

5. Do you have any hip, back, knee or other joint or muscle problem that affects your ability to cycle?

YES NO

6. Do you have any condition which affects your motor skills?

YES NO

7. Are you currently taking any drugs or medication for conditions affected by exercise?

YES NO

8. Is there any other reason you should not participate in physical exercise at present?

YES NO

If you answered YES to any of the above questions, please give details below:

9. Do you have any additional learning requirements? (e.g Dyslexia, English as a second language)

YES NO

If you answered YES to Q9 above, please give details below

10. How long have you been doing indoor cycling classes? (Any brand)

Never Less than 1 year Between 1- 5 years More than 5 years

11. If you are a class regular, which brands have you participated in?

12. Do you have other fitness qualifications already?

YES NO

13. If you have previous fitness qualifications, please list below

14. Are you a member of CIMSPA, NASM, AFAA or other fitness body?

YES NO

15. If you answered YES to Q14 above, please list the companies you are registered with below:

16. Please identify your prior online training experience

17. Please send us your OS and browser details:

Click here, then copy and paste the link content into the box below

I confirm the information above is correct and there is no reason why I cannot participate safely and fully in this training and associated practical practice

YES

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