This liability waiver, (“Agreement”), is entered into by and between SpoonMoon LIC, an Arkansas limited liability company, and its related entities and affiliates, (“SpoonMoon”) and____________________, an individual and resident of Arkansas (“Participant”).

Name (Last, First): ____________________
Mailing Address: ____________________
Phone Number: ____________________
Email Address: ____________________

Participation in Fitness/Wellness programs, classes, and related services is voluntary and, if necessary, should be undertaken on the basis of personal medical advice.

Completion of the PAR-Q (Physical Activity Readiness Questionnaire) is mandatory for participation.

1. Has a doctor or medical professional 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 that could be made worse by a change in your physical activity?
Yes- • No-•
6. Is your doctor currently prescribing drugs for your blood pressure or heart condition?
Yes-• No -•
7. Are you currently injured in any manner that would limit your physical activity?
Yes-• No.•
8. Do you know of any other reason why you should not do physical activity?
Yes- • No-•

If you answered YES to one or more questions: Talk with your doctor by phone or in person BEFORE you start becoming more physically active or BEFORE you participate in a fitness/wellness activity. Tell your doctor about this questionnaire 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 you wish to participate in and follow his/her advice.
• Find out which fitness/wellness activities are safe and helpful for you.

If you answered NO to all questions: If you answered NO honestly to all eight questions, you con:
• Become more physically active—begin slowly and build up gradually.
• Take part in fitness/wellness activities.

You are not feeling well because of a temporary illness or injury-wait until you feel better; or
• You are or may be pregnant—talk to your doctor before you start becoming more active.

SpoonMoon, LLC assumes no liability for individuals who undertake physical activity or participate in physical or wellness programs, classes, or services, and if in doubt after completing this questionnaire, consult your doctor prior to physical activity.

I have read, understood, and completed this questionnaire truthfully. Any questions I had were answered to my full satisfaction.

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