Rollerski Safety




			Safety questionnaire and informed consent Come along to your first session prepared. Print out this form, fill it in, and bring it along to your first session. Please bring gloves with you, and a cycle helmet if you have one - we provide all other equipment. Forename:............................................................. Surname:.............................................................. Date of Birth dd/mm/yy: __ / __ / __ Address:................................................................................................................................... ................................................................................................................................................ Postcode:................................................... Tel (Home):.................................................Tel (Work):.............................................................. Fax:...........................................................Mobile:.................................................................... Email:....................................................................................................................................... Can we contact you with our news, by mail or email: Yes / No Occupation:............................................................................................................................... Please answer the following Questions and sign below: Yes / No 1. Has your doctor ever said you have heart trouble? 2. Have you ever had pains in your chest? 3. Do you often feel faint or have spells of dizziness? 4. Has a doctor said your blood pressure is too high? 5. Has a doctor said that you might have bone or joint problems, such as arthritis, that has been aggravated by exercise or might be made worse with exercise? 6. Have you been in hospital in the last 3 years? 7. Are you currently taking any medication? 8. Are you Pre/Post natal? 9. Do you suffer from asthma, or breathing difficulties? 10. Do you suffer from diabetes or epilepsy? 11. Do you suffer from an allergy? 12. If ‘Yes’ what medication do you take? 13. Is there a good physical reason not mentioned here why you should not follow an activity programme? If you have answered ‘Yes’ to one or more questions...... If you have not recently done so, consult with your doctor before increasing your physical activity and tell your doctor which questions you answered yes to. If in any doubt, seek your doctor’s advice as to your suitability for unrestricted physical activity that progresses gradually. --------------------------------------------------------------------------------------------------------- How would you describe your current level of fitness?: (please tick) O - Very fit O - Fit O - Average O - Unfit O - None at all --------------------------------------------------------------------------------------------------------- Informed Consent - Liability Waiver In consideration of being allowed to participate in the activities and programmes of Rollerski Instruction / London Cross-Country Ski Club and to use the facilities and equipment owned and/or under the control of Rollerski Instruction / LCCSC, in addition to the payment of any fee or charge, I do hereby waive, release and forever discharge Rollerski Instruction / LCCSC from any and all responsibility or liability for injuries or damages resulting from my participation in any activities or my use of equipment or facilities in the above mentioned activities. I understand and I am aware that strength, flexibility and aerobic exercise, including the use of equipment, in the outdoors, are potentially hazardous activities. I also understand that exercise and fitness activities involve a risk of injury and even death, and that I am voluntarily participating in these activities and using equipment and facilities with the knowledge of the dangers involved. I hereby agree to expressly assume and accept all and any risks of injury or death. I am aware that I have the right to request advice from any of Rollerski Instruction / LCCSC's instructors, at any time, in relation to the activities and exercise being undertaken and, but not exclusively, their suitability for me, with particular regard to my health and clothing. If I choose not to take advice, or to disregard any advice so given, I do so voluntarily and accept liability for all resulting injuries or damage. I do hereby declare myself to be physically sound and suffering from no condition, impairment, disease or infirmity or other illness (other than those declared on the attached medical questionnaire) that would prevent my participation or use of equipment or facilities except as herein stated. I acknowledge that I have either had a physical examination and have been given my doctors permission to participate, or that I have decided to participate in activity and use of equipment and machinery without the approval of my doctor and do hereby assume all responsibility for my participation and activities, and utilisation of equipment and machinery in my activities. In addition Rollerski Instruction / LCCSC cannot accept responsibility for valuables left in the instructors vehicles. Where did you hear about us?................................................... Signature:.................................................................................... Date:............................................................................................ Print name:.................................................................................. Now bring this form along with you to your first session. Please bring your own gloves, and a cycle helmet if you have one. We look forward to you getting you rolling! Objectives questionnaire It's useful for us to have an idea of what you'd like to get out of roller skiing. Please rate the following out of 5 - through rollerskiing, I'd like to: 1. Improve or maintain my general fitness 2. Have a bit of fun doing something completely different 3. Prepare for a cross-country ski holiday 4. Prepare for a cross-country ski race 5. Prepare for downhill skiing 6. Cross-training for another sport 7. Lose weight 8. Try a low impact subsitute for running 9. To build up specific strength or core strength If you are training towards a particular goal, please state and give timescale. (eg I'm preparing for a cross-country ski holiday in January or for a ski race in March). ................................................................................................................................................ If you have any other comments which might help us understand your goals or better develop your programme, please state below. ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................