Leisure and Culture Dundee are advocates of using physical activity as a means of promoting a healthy lifestyle. In most cases, physical activity does not pose any problems or hazard to health however there are some cases where exercise should be avoided or approached with caution. This PARQ has been designed to identify any potential risk factors that may contribute towards problems or hazards you may experience when exercising. Please complete the following accurately, with as much detail as possible. To be completed by the parent or guardian. Personal Details Name of child/young person * Date of birth * Address Emergency Contact Information Emergency contact 1 Name * Relationship * Contact Number * Emergency contact 2 Name * Relationship * Contact Number * Medical History Does your child have, or ever experienced, any of the following? Please select all relevant answers. Chest pain brought on by physical exertion Yes No Diabetes Yes No Epilepsy Yes No Dizziness or fainting Yes No A bone, joint, or muscular problem Yes No Asthma or any other respiratory problems Yes No Any sustained injuries or illnesses Yes No Any allergies Yes No Is your child taking any medication Yes No Has anyone in your family had any heart problems at a young age Yes No Additional Information Is there any reason not mentioned above why any type of physical activity may not be suitable for your child Yes No Additional Information Declaration In signing this form, I the parent/guardian of the aforementioned child, affirm that I have read this form in entirety and I have answered the questions accurately and to the best of my knowledge * YES I understand that if the instructor requires further information about my child’s illness or disability in order to include him/her in activities I will endeavour to make sure this information of available to him/her * YES Signed Date *