╨╧рб▒с>■  FH■   E                                                                                                                                                                                                                                                                                                                                                                                                                                                ье┴ @ ∙┐44bjbj╩Ъ╩Ъ "6иЁиЁ|      И·······ЎЎЎЎ4*  юJ ▄& & & ║ Х Ь1 dХ 4WYYYYYY$R`Ї}]·╔ Х Х ╔ ╔ }··& ║ █┌ЙЙЙ╔ ·& ·║ WЙ╔ WЙЙОIh··╤& Ф> Рp"Зп╔Ў╙ "▒WЁ0 ┴T ї ИT ╤····╤VT ·'0╔ ╔ Й╔ ╔ ╔ ╔ ╔ }}ф} Physical Activity Readiness Questionnaire (PAR-Q) and Waiver of Liability Name:  FORMTEXT       Date:  FORMTEXT       Please read the questions carefully and answer each one honestly: Answer YES or NO. Has your doctor ever said that you have a heart condition?  FORMTEXT       Has your doctor ever told you that your blood pressure was too high?  FORMTEXT       Do you experience loss of balance due to dizziness or do you ever lose consciousness?  FORMTEXT       Do you have a bone or joint problem that is aggravated by physical activity?  FORMTEXT       Do you have high cholesterol?  FORMTEXT       Are you over 65 years of age and not accustomed to vigorous exercise?  FORMTEXT       Are you pregnant?  FORMTEXT       Do you know of any other reason that would not allow you to participate in a physical fitness program?  FORMTEXT       If Yes, Explain:  FORMTEXT       In consideration of being allowed to participate in the activities and programs of (Jennifer Myers and Exercise On The Net) in addition to the payment of any fee or charge, I do hereby waive, release and forever discharge (Jennifer Myers and Exercise On The Net) and all others from any and all responsibilities or liability from injuries or damages resulting from my participation in any activities, or my use of equipment or machinery in the above mentioned activities. I do also hereby release all of those mentioned, and any others acting upon their behalf, from any responsibility or liability from any injury or damage to myself, including those caused by the negligent act or omission of any of those mentioned or others acting on their behalf, or in any way arising out of or connected with my participation in any activities I understand and am aware that strength, flexibility, and aerobic exercise, including the use of equipment, are a potentially hazardous activity. I also understand that fitness activities involve a risk of injury and even death, and that I am voluntarily participating in these activities and using equipment and machinery with knowledge of the dangers involved. I hereby agree to expressly assume and accept any and all risks of injury or death. I do hereby further declare myself to be physically sound and suffering from no condition, impairment, disease, infirmity or other illness that would prevent my participation or use of equipment or machinery except as hereinafter stated. I do hereby acknowledge that I have been informed of the need for a physicianТs approval for my participation in an exercise/fitness activity or in the use of exercise equipment and machinery. I also acknowledge that it has been recommended that I have a yearly or more frequent physical examination and consultation with my physician as to physical activity, exercise and use of exercise and training equipment so that I might have his/her recommendations concerning these fitness activities and equipment use. I acknowledge that I have either had a physical examination and been given my physicians permission to participate, or that I have decided to participate in activity and use of equipment and machinery without the approval of my physician and do hereby assume all responsibility for my participation and activities, and utilization of equipment and machinery in my activities. User acknowledges these physical activities involves the inherent risk of physical injuries or other damages, including, but not limited to, heart attacks, muscle strains, pulls or tears, broken bones, shin splints, heart prostration, knee/lower back/ foot injuries and any other illness, soreness, or injury however caused, occurring during or after userТs participation in the physical activities. User further acknowledges that such risks include, but are not limited to, injuries caused by the negligence of an instructor or other person, defective of improperly used equipment, over exertion of User, slip and fall by User, or an unknown health problem of User. User agrees to assume all risk and responsibility involved witdfЦавд╕║╝╞╚╘╪┌юЁЄ№■ Д И к э▐э═┐н┐Хн}н═┐н┐eн}н═Q@Q hШeN5БCJOJQJ\Б^JaJ&hШeNhщ75БCJOJQJ\Б^JaJ/Бjth kЮh kЮCJOJQJU^JaJ.jh kЮCJOJQJU^JaJmHnHu/Бjh kЮh kЮCJOJQJU^JaJ#jh kЮCJOJQJU^JaJh kЮCJOJQJ^JaJ hШeNhщ7CJOJQJ^JaJhШeN5БCJOJQJ^JaJ#hШeNhщ75БCJOJQJ^JaJfЦ╩ Ж к J ■ ╘ Ш ■ ┤ Hчз┘.ЁЁ└!6Чыы▀└!ыZ▀└!ыZ▀▀▀▀▀▀▀▀╨ └!ыZ┴└!ыZ▓└!ыZг & Fдdдd[$\$gdщ7 & Fдdдd[$\$gdщ7 & Fдdдd[$\$gdщ7 & Fдdдd[$\$gdщ7 дdдd[$\$gdщ7gdщ7$дdдd[$\$a$gdщ744■к  " $ 8 : < F H ╥ ╓ ╪ ь ю Ё · № и м о ┬ ─ ╞ ╨ ╥ ╘ l э▐╩▐░╩Ч╩э▐╩▐}╩Ч╩э▐╩▐c╩Ч╩эP$hШeNhщ70JCJOJQJ^JaJ2Бj╨h kЮh kЮCJOJQJU\Б^JaJ2Бj\h kЮh kЮCJOJQJU\Б^JaJ1jh kЮCJOJQJU\Б^JaJmHnHu2Бjшh kЮh kЮCJOJQJU\Б^JaJ&jh kЮCJOJQJU\Б^JaJh kЮCJOJQJ\Б^JaJ#hШeNhщ7CJOJQJ\Б^JaJl p r Ж И К Ф Ц ╥ ╓ ╪ ь ю Ё · № ■ И М О в д ж ░ ▓ ╓ ┌ ▄ Ё Ё▄Ё─▄к▄ЧЁ▄Ё▄к▄mЧЁ▄ЁU▄к▄ЧЁ▄Ё/Бj,h kЮh kЮCJOJQJU^JaJ#hШeNhщ7CJOJQJ\Б^JaJ/Бj╕h kЮh kЮCJOJQJU^JaJ$hШeNhщ70JCJOJQJ^JaJ2jh kЮ0JCJOJQJU^JaJmHnHu/БjDh kЮh kЮCJOJQJU^JaJ'jh kЮ0JCJOJQJU^JaJh kЮ0JCJOJQJ^JaJЁ Є Ї ■ ╬╥╘шъьЎ°№ч╙╣╙жУГoГWo=oГ, hШeNhщ7CJOJQJ^JaJ2jh kЮ0JCJOJQJU^JaJmHnHu/Бjh kЮh kЮCJOJQJU^JaJ'jh kЮ0JCJOJQJU^JaJh kЮ0JCJOJQJ^JaJ$hШeNhщ70JCJOJQJ^JaJ$hШeNhщ70JCJOJQJ^JaJ2jh kЮ0JCJOJQJU^JaJmHnHu'jh kЮ0JCJOJQJU^JaJ/Бjаh kЮh kЮCJOJQJU^JaJ "68:DFHч,ы-ь-я-Ё-╪.┘.┌./d/f/n/o/ЄрЄ╚р░рЬЛЙЛ{Л{ЛmЄ[L;Лр h kЮh kЮCJOJQJ^JaJh kЮ6БCJOJQJ^JaJ#h kЮh kЮ6БCJOJQJ^JaJhщ7CJOJQJ^JaJhШeNCJOJQJ^JaJU hШeNhщ7CJOJQJ^JaJ'hШeNhщ70J5БCJOJQJ^JaJ.jh kЮCJOJQJU^JaJmHnHu/БjКh kЮh kЮCJOJQJU^JaJ#jh kЮCJOJQJU^JaJh kЮCJOJQJ^JaJh participation in the physical activities. User affirms that User is in good physical condition and does not suffer from any disability that would prevent or limit participation in the physical activities. User acknowledges participation will by physically and mentally challenging, and User agrees that it is the responsibility of User to seek competent medical or other professional advice, regarding any concerns or questions involved with the ability of User to take part in Exercise On The Net Physical Activities. By signing this agreement, User asserts that he or she is capable of participating in the physical activities. User agrees to assume all risk and responsibility for not exceeding his or her physical limits. Your typewritten name with the email submission data will act as a signature and signify that all of the information provided is accurate. 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