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. A separate form is required per individual child. Compulsory data is indicated by * PARTICIPANT DETAILS Child Forename * Child Surname * Date of Birth * Day12345678910111213141516171819202122232425262728293031 Day MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Year2007200820092010201120122013201420152016201720182019202020212022202320242025 Year Activity PARENT/GUARDIAN DETAILS Parent Forename * Parent Surname * Telephone No. * Email Address * EMERGENCY CONTACT DETAILS Emergency contact 1 Name * Relationship * Contact Number * Emergency contact 2 Name * Relationship * Contact Number * MEDICAL INFORMATION Does your child have, or ever experienced, any of the following? Please circle 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 PHOTO/FILMING CONSENT LACD manage a strict policy on the taking and using of video and photographic images. Participants and members of the public are not permitted to take photographs or videos at LACD activities. LACD obtain consent to enable officers and members of the press to take video or photographic images for official use only. These images may be used on the LACD website, for promotional material or social media for promotional purposes only. I (the parent/guardian) give permission for my child to be in any photographs or videos for the above purposes only. YES NO CODE OF CONDUCT LACD asks participants and their carers to adhere to its Codes of Conduct to ensure the health, safety and enjoyment of all participants. Failure to do so could result in the participant being excluded from the class/activity. Examples included in the Code of conduct are: Be safe at all times. Follow the instructions and listen to the activity leader at all times. Respect each other- no hitting/pushing/put downs or swearing. Take care of all property and equipment being used. Do not leave sessions without the permission of those in charge. The full code of conduct can be viewed on our website at https://www.dundeecity.gov.uk/forms/AdobeDocs/codes_of_conduct.pdf I confirm that I have read and acknowledge the code of conduct. * DATA PROTECTION The personal information you have provided will be held by LACD and only used for the following purposes: To contact you about your chosen course or activity. To provide relevant medical information to staff or emergency services in the event of an accident/ incident. For the prevention and detection of crime. If you have any questions about our Data Protection Policy or the information we hold about you, please contact us on 01382 307485 or email: dataprotection@leisureandculturedundee.com LACD would like to send you information electronically on relevant activities with our Teen Programme in the future. Please indicate if you wish to receive activity information for our Teen Programme by ticking the box below. I wish to receive information on our Teen Programme in the future * Yes No You can opt out of these emails at any time by contacting leisureactive@leisureandculturedundee.com. SIGNATURE 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 * Day12345678910111213141516171819202122232425262728293031 Day MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Year2025 Year Leave this field blank Submit
