Velocity PARQ and Terms

Please only fill out this form if you have completed the Direct Debit form.

You will be required to upload/take a photo of yourself and make your sign up payment (£15)as well

First name

Email Address

Last name

Date of Birth

Phone

Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?

Yes

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

Yes

In the past month, have you had a chest pain when you were not doing physical activity?

Yes

Do you lose balance because of dizziness or do you ever lose consciousness?

Yes

Do you have a bone or joint problem ( for example back, knee or hip) that could be made worse by a change in your physical activity?

Yes

Is your doctor currently prescribing medication for your blood pressure or heart condition?

Yes

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

Yes

If YES, please comment:

I have read, understood and accurately completed this questionnaire. I confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury.

Having answered YES to one of the questions above, I have sought medical advice and my GP has agreed that I may exercise

Please upload a picture of your face for your membership.

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I agree to the Velocity Gym rules, failure to adhere to these rules may revoke my membership, without financial compensation.View terms of use

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Today's Date

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01263 732180

PARQ Form

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