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Always consult your physician before beginning any exercise program.
PAR-Q FORM: Please mark YES or No to the following:

Has your doctor ever said that you have a heart condition and recommended only medically supervised physical activity?
YESNO

Do you frequently have pains in your chest when you perform physical activity?
YESNO

Have you had chest pain when you were not doing physical activity?
YESNO

Do you lose your balance due to dizziness or do you ever lose consciousness?
YESNO

Do you have a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program
(i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia, anemia, epilepsy, respiratory ailments, back problems, etc.)?
YESNO

Are you pregnant now or have given birth within the last 6 months?
YESNO

Have you had a recent surgery?
YESNO

If you have marked YES to any of the above, please elaborate below:

Do you take any medications, either prescription or non-prescription, on a regular basis?
YESNO

What is the medication for?

How does this medication affect your ability to exercise or achieve your fitness goals?

IF YOU ANSWERED YES to one or more questions:
Talk with your doctor by phone or in person BEFORE you start becoming much more physically active or participating in this running program.
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 and follow his/her advice.
IF YOU ANSWERED NO to all questions:
and you feel you may start becoming more physically active, still use discretion. Begin slowly and build up gradually.

Please read the following consent/liability release form below:
I acknowledge that running, boot camps, weight training, obstacle courses, and any other related sports are an extreme test of one's mental and physical limits and carry with it potential for damage or loss of property, serious injury and death. I, the undersigned, assume the risks of participating in these types of events/activities. I, the undersigned expressly waive, release, discharge and agree not to sue from any liability of death, disability, personal injury, or action of any kind Unleashed Fitness, LLC (Kerry Kilduff, Dan Newton & Kelly Willing),or its partners or associates for the undersigned participating in said training and or sporting events.
Unleashed Fitness, LLC (Kerry Kilduff, Dan Newton & Kelly Willing and its trainers) shall not be liable for any injuries or damages to me, or subject to any claim, demand, injury or damages, whatsoever, including action. I acknowledge that I have carefully read this paragraph and fully understand that this is a waiver and release of liability. It is my responsibility to insure that I am physically able to participate in this program. Only a doctor can advise me on my ability to participate. By my signature below, I am acknowledging that I have been given the opportunity to obtain that advice and that I have been advised that I can participate.

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If under 18, a parent or guardian will sign above

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