EmailMe Form - Consultation & PARQ Form

Completed 'People Move Stress Less Feel Alive System Program registration consultation and PARQ forms' are handled by Jessica Blackbond. Information you provide is stored on our servers for 12 months and deleted after this time. Jessica will use the information you provide to contact you if necessary. *

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I disagree

Name *

First Last

Date of Birth

MM / DD / YYYY

Email *

Telephone Number *

Address *

City *

County *

Postcode / Zipcode *

Country *

Conditions and/or Symptoms. Please tick the box(es) that apply to you *

Please give details if you answered yes to any of the above conditions and / or symptoms; or give details of any other condition / symptom not listed here *

Do you exercise regularly? *

Yes

No

Are you taking any medication? *

Yes

No

If you have answered yes to the above question, please consult with your GP before starting the Feel Alive System Program.
Please give a general description of the medication you are taking below: *

What is your occupation? *

How would you describe your energy levels? *

High

Medium

Low

How would you describe your sleep patterns? *

Good

Average

Bad

How would you describe your stress levels? *

High

Medium

Low

What do you do for relaxation? *

For ladies only... Could you be pregnant? If yes, how many weeks?

Please use the space below to inform People Move Stress Less of any injuries or physical problems you have when it comes to exercising - modifications can be made to help you :-)

Client Declaration: I declare that I have read and understood this consultation form and the information I have given is true and correct, to the best of my knowledge.

I declare that I can participate in the 'Feel Alive System Program' with People Move Stress Less; withdrawing all rights to make any claim and will not hold Jessica Blackbond or People Move Stress Less responsible for any problems or side effects as a result of my participation.

I understand that participation in the 'Feel Alive System Program' is not a substitute for medical advice and/or treatment.

I agree to pay People Move Stress Less the full program fee before commencing the online learning.

To agree with this statement, please complete your full name and today's date below:

Date of Consultation Form completion and submission

MM / DD / YYYY

Thank you for completing the People Move Stress Less Feel Alive System 6-Week Program registration form.

Once you press the submit button your form will be sent to Jessica Blackbond. You are welcome to read our Privacy Policy and Terms and Conditions at https://www.peoplemovestressless.com/pages/privacy

Please provide any comments regarding this form below if you feel you would like to give any...

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