Participant PAR-Q

16+ Student PAR-Q

* Indicates required field

Student's Full Name *

First

Last

Date of Birth *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Gender *

Email *

Phone Number *

Emergency Contact *

Emergency Contact Phone Number *

Medical Questionnaire - Please check the box if you answer "yes" to any of the following questions *

Has your doctor or other health care professional advised you not to participate in physical activity? Do you have any illness or disability which would limit your taking part in physical activity? 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? Do you have any allergies? Are you on any medications? Do you have any history of high / low blood pressure, eye problems (e.g. detached retina), stroke, cholesterol problems, heart disease or vertigo? Do you suffer from dizziness or shortness of breath when exercising? Do you have any transmittable or blood diseases? Do you have any back, neck or joint problems? Have you had any operations within the last five years? Are you currently or have you recently been pregnant? Do you know of any other reason why you should not take part in physical activity? None of the above apply to me

If you have ticked "Yes" for any of the questions on the medical questionnaire, please provide further details here. *

Have you ever taken part in a similar class before? *

Yes No Unsure

If you have taken part in similar classes before, please state the level of achievement *

Is there a particular skill or piece of equipment that you enjoyed the most? Is there anything you'd like Rosie or other instructors to know? *

Do you regularly take part in any exercise? *

Yes No

What kind of exercise do you enjoy? *

What does your average week's exercise look like at the moment? *

Any other information? *

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...) *

Yes No

Standard Informed Consent - Please tick to confirm that you have read and accepted each statement. *

Wherever possible, we will accommodate any individual because Circus should be accessible for every body. Adjustments may need to be made, medical advise sought or a doctors 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 potentially 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 forseeable at the time you submit this agreement. You understand that it is your responsibility to communicate any physical and / or mental impediments 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.

Video / Photography Consent *

I give permission for photographs and videos to be taken and published in the private Facebook group for members of my class & their families. I give permission for images of me to appear in promotional photography / video clips of Rosie Rainbow Circus / Untamed Events / Unbroken Circus' sessions. This material may be used on the website, Facebook, Instagram or on other promotional media I give permission for Rosie Rainbow / Unbroken Circus / Untamed Events to tag me in these images. My social media is below:

Social Media Tags *

Please confirm that you agree to be added to Unbroken Circus' newsletter mailing list in relation to offers / events / information *

YES I'd love to know what's happening NO I do not want to be updated