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PARQ FORM

Young Persons Physical Activity Readiness Questionnaire

Dear Parent / Guardian,

There are many health benefits to be gained when children and young people exercise regularly. It issensible however to consider their health status prior to commencing a physical exercise programme. Thisquestionnaire aims to identify your childs health status so that we can provide exercise advice and avoid anyrisk of injury or illness.

Young Persons Registration Information

First Name: Surname: ..

Address: .

.

Postcode: Home No: Mobile No: ..

Gender: Male / Female (please circle) Date of Birth: ..

The following questions relate to the health of the young person. Please read the questions carefully andprovide a correct answer by circling Yes or No. Where necessary, please provide details.

Details

Has a doctor ever diagnosed your child with aheart condition?

Yes No

Has your child recently had chest pains duringor after exercise?

Yes No

Does your child ever feel faint or have spells ofsevere dizziness?

Yes No

Is your child currently receiving treatment ormedication for high blood pressure?

Yes No

Is your child currently receiving treatment ormedication for any other condition?

Yes No

Has your child broken any bones in the past sixmonths?

Yes No

Does your child suffer from any bone or jointproblems which exercise may aggravate? Yes No

Does your child suffer from epilepsy or chronicasthma?

Yes No

Is your child diabetic? If yes, is the diabetestype 1 or Type 2?

Yes No

Has your child undergone any recent surgery?Yes No

Is there any other reason which has not beenmentioned that may affect your child if theytook part in physical activities?

Yes No

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It is important to note that if you have answered YES to any of the above questions, there may berestrictions on your childs ability to participate in exercise programmes. If you are unsure of any of theinformation you have provided we strongly advise that you consult with your Doctor before allowing yourchild to begin any exercise programme.

Parent / Guardian Declaration

1. I confirm that the above answers are correct, at this point in time, to the best of my knowledge andbelief.

2. I will ensure that I inform the coach at once if any of the above information changes.

3. I agree that my child will abide by the rules of Queens Sport and follow the instructions of staff at all

times.

Signature:

Print Name ..

Relationship to Child ..

Date

Coaches Signature ..

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