Health Questionnaire

This form includes a Physical Activity Readiness Questionnaire, the program liability waiver, and questions that help us with our program evaluation. Your name and information will never be shared and is only collected to ensure we have a registration form completed for all class attendees.

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Email(Required)

What is your name?(Required)

First Last

(or the first & last name of the class participant if you are a guardian completing this for a minor)

What is your age?(Required)

Please check one or more of the following groups in which you consider yourself to be a member. Please use other if none of these descriptions fit.(Required)

Hispanic or Latino

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Middle Eastern or North African

Prefer not to answer

Other

If other, please type answer here:

I prefer to identify as(Required)

Male

Female

Non-binary

Prefer not to answer

What is your height (ie. 5' 10")?(Required)

What is your weight in pounds?(Required)

What is your zip code?(Required)

Are you an employee of Chesterfield County Government or Schools?(Required)

Yes

Emergency Contact Name(Required)

First Last

Emergency Contact Phone(Required)

Program Evaluation Questions

The following questions help us to evaluate the effectiveness of our program. These questions serve as a pre-survey. Twice per year we conduct surveys that will have similar questions so we can compare the two sets of data.

How many minutes per week are you physically active (walking, sports, dance, Warriors classes, etc)? Select One.(Required)

0 minutes/week

1-30 minutes/week

31-60 minutes/week

61-90 minutes/week

91-120 minutes/week

121-150 minutes/week

150+ minutes/week

Current Level of Fitness

Rate your current level of physical fitness on a scale of 1 (very low) to 5 (very high) by selecting a number below.

Energy Level(Required)

1 (Low)

5 (Very High)

Level of Flexibility(Required)

1 (Low)

5 (Very High)

Level of Strength(Required)

1 (Low)

5 (Very High)

Level of Cardio Endurance(Required)

1 (Low)

5 (Very High)

Goals

Do your goals include any of the following? Please indicate yes or no for each of the following potential goals.

Lose weight for health reasons(Required)

Yes

Reduce the amount of medications I currently take(Required)

Yes

Reduce stress(Required)

Yes

Improve my ability to function in my daily activities and tasks(Required)

Yes

Feel confident exercising in front of others(Required)

Yes

Be knowledgeable about physical fitness(Required)

Yes

Have a positive outlook on life(Required)

Yes

How'd you hear about us?

How did you hear about the Fitness Warriors class?(Required)

Warrior Facebook

Warrior Instructor

Word of Mouth

Warrior Instagram

Community Event

Sports Backers Website

Paper Materials

Prefer not to answer

Other

Physical Activity Readiness Questionnaire

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

Yes

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

Yes

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

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?(Required)

Yes

Is your doctor currently prescribing medication for your blood pressure or a heart condition?(Required)

Yes

Do you lose your balance because of dizziness or do you ever lose consciousness?(Required)

Yes

Do you know of any other reason why you should not do physical activity?(Required)

Yes

If you answered ‘Yes’ to any of the Physical Activity Readiness questions:

Talk with your doctor by phone or in person BEFORE you start becoming much more physically active. Tell your doctor about the PAR-Q and which questions you answered YES. You may be able to do any activity you want – as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those which are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow their advice. If you plan to participate in the Fitness Warriors class, please make your instructor aware of any of the reasons you answered “yes” to the Physical Activity Readiness Questions.

Participant Waivers

Each new participant, or their parent/guardian for participants under the age of 18, will need to complete the following waivers prior to participating in the Fitness Warriors program.

Fitness Warriors Program Participation Rules

In consideration of my participation in any fitness class conducted as part of the Fitness Warriors Program, I, on behalf of myself acknowledge, accept and agree to the following:

Participation Rules(Required)

I agree to not participate if I am not physically able to or been advised to not participate.

I agree to inform the instructor of any relevant medical conditions or limitations prior to participation.

I agree to report all injuries (even minor injuries) to the lead instructor.

I agree to wear appropriate fitness equipment during participation in the class.

I agree to follow all rules of the class and the instructor.

I agree to stop participation in the class if the instructor asks me to stop.

I agree to stop participating if at any time I or my Ward feel the conditions are unsafe.

Fitness Warriors Program Participation Rules(Required)

I have read the Fitness Warriors Program Participation Rules and agree to abide by them at all times.

Promotional Rules

I, on behalf of myself, and if applicable, irrevocably grant unlimited permission to the Sports Backers to use photos and videos recorded during any Fitness Warriors Program class for any legitimate purpose in perpetuity and that I will not be entitled to any compensation in connection therewith.

Fitness Warriors Promotional Rules(Required)

I agree with the Fitness Warriors Program Promotional Rules.

Assumption of Risk / Participant Waiver

I know that participating in a fitness class is a potentially hazardous activity. I will not register and participate unless I am qualified, in good health, medically able, and properly trained. I assume all risks associated with this class including, but not limited to: falls, contact with other participants, the effects of weather, including high heat and/or humidity, the conditions of the facility, potential exposure to communicable disease (including but not limited to coronavirus/COVID-19, other viruses, bacteria, and all other infectious pathogens and disease vectors), all such risks being known and appreciated by me. I understand the physical demands of the activity may result in injury or medical complications, including those related to pre-existing conditions. I acknowledge that if I believe class conditions are unsafe, I will immediately discontinue participation in the class. I fully accept and assume all responsibility for losses, costs, and damages I incur as a result of my participating in this class. I agree to abide by any decision of the instructor and program official relative to my ability to safely complete the class. Having read this waiver, knowing these facts, and in consideration of accepting my entry, I for myself and anyone entitled to act on my behalf, discharge, waive, and release the Metropolitan Richmond Sports Backers, Fitness Warriors instructors and any other partners and sponsors, along with their officers, directors, agents, volunteers and employees from all claims or liabilities of any kind arising out of my participation in this class.

Fitness Warriors Program Participation Rules(Required)

I agree with the assumption of risk/participant waiver.*