Name :
DOB :
Address:
Contact tel:
Email:
Physical Activity Readiness Questionnaire ( please answer YES or NO)
1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
YES
NO
2. Do you feel pain in your chest when you do physical activity?
YES
NO
3. In the past month, have you had chest pain when you were not doing physical activity?
YES
NO
4. Do you lose your balance because of dizziness or do you ever lose consciousness?
YES
NO
5. 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?
YES
NO
6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
YES
NO
7. Do you know of any other reason why you should not do physical activity?
YES
NO
I understand that American Football is a collision sport involving impacts

of considerable force. I confirm that my participation in the sport can be potentially dangerous and the likelihood of injury is constantly present. I hereby voluntarily consent to my participation in all club practise sessions, games and fitness testing. I understand that participating in any of the above mentioned sessions could involve progressively higher levels of physical activity and that I may be encouraged to work at maximum effort.
I confirm that I am responsible for monitoring my own condition throughout my participation in games, practise and all physical testing. Should any unusual symptoms occur, such as but not limited to chest discomfort, nausea, difficulty in breathing, dizziness, light headedness, irregular heart beat and joint or muscle injury, I will cease my participation and inform the test administrator, trainer and/or coach of the symptoms.
Also, in consideration of being allowed to participate in club games, practise sessions and all physical testing sessions, I confirm that I have disclosed all medical issues relating to my health and I agree to assume all potential risks from such participation and hereby release and hold harmless Gateshead
Senators and their agents and employees, from any and all health/medical issues that may be aggravated or arise from my participation in any physical activity organised by the club.
I have read the foregoing carefully and I understand its content. Any questions which may have occurred to me concerning this informed consent have been answered to my satisfaction.
Players Signature: _ _ _ _ _ _ _ _ _ _ _ _ _ _
Parents Signature (U18):_ _ _ _ _ _ _ _ _ _
Date:_ _ _ _ _ _ _ _ _