The following is the Intake Form which we use for these classes, new joiners are required to complete this before the first class, as a check of your current state of health and fitness and for agreement to take part. This form is also an agreement (by yourself) that all liability and responsibility for training and taking part remains wholly with yourself, and not with myself nor with Harrow Carers, so please make sure you are fit and well-enough to practice, check with your GP beforehand if you wish or need to. These forms are held under the latest GDPR compliance rules for data handling and confidentiality; it will not be shared with anyone else or uploaded to the web. Do let me know if you would like a copy of yours and I will provide this to you.
Please note this is a read-only online version. The pdf version is available below for downloading, so you can fill it in before you come along.
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ksQigong Classes and Practice Consent & Disclaimer Form (For Harrow Carers). ver. 8
First Name and Surname: ……………………………………………………………………………………………… (use Capitals)
Home Address: …………………………………………………………………………………………….
…………………………………………………………………………………………….
Post Code: ……………………………………………………………………..
Email Address: …………………………………………………………………………………..
Mobile/Tel No. …………………………………………………………………………………..
Emergency Contact .. Name: ………………………………………………………………………………………
Contact No. ……………………………………………………………………………..
Have you done Qigong, Tai Chi, Yoga or other similar exercise routines before? Yes / No (circle)
If so, which and for how long? ……………………………………………………………………………………………………………………………………………………………………………………………………………………………..
How would you describe your current fitness level? Poor / Low / Medium / Good / High (circle)
*Do you have any injuries or health issues that may affect your training here? Yes / No (circle)
If so, which? Noting that low/high blood pressure, most forms of epilepsy, psychosis or a recent operation (even frailty) will affect your ability to do these classes, please let me know if these relate to you before training. Please answer as fully as you can, using the reverse side of this form (paper), if needed.
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*Important: Please check with your GP/medical expert that you can engage in these classes beforehand, and If I have any concerns about your suitability for these classes, I may ask you to provide a letter from your GP stating they believe you are fit enough for them.
I knowingly sign this consent form in the understanding that I assume all responsibility for any injuries, damage or discomfort to me that may arise during my participation in these classes, or on my own (e.g. at home). These group sessions will never (nor must ever) be recorded, either via audio or video.
I understand all of the above and hereby waive any rights to bring legal action or assert a claim against the trainer (Kail, ksQigong, as Agent) or Harrow Carers (as Principal Supplier) for any injury or discomfort arising.
By signing below, you are providing your informed consent to engage in the training.
Signed: ……………………………………………………….. Date: ………………………………………………………..
This data will be kept confidentially, securely and under GDPR Compliance and Data Protection Act 2018. Your details may be used to contact you via email or mobile number (e.g. WhatsApp) and on a secure and private client database, which will never be shared with anyone else (person or company), and never uploaded to the web. Please ask me for a copy of this completed form, should you want it.
Thank you.
In Strictest Confidence. Ver 8 (28/10/24)
To download this file (pdf), click below (NB: it will open in a new tab):-