Waiver

Age:

Emergency Contact Name:

Emergency Contact Phone Number:

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

E-Signature:

Waiver Agreement:

By checking this box, you acknowledge that you have read and agree to the terms of the waiver, and you indicate that [Company Name] is not responsible for any physical injury, illness, or damage resulting from participation in activities. You understand that participation is voluntary and at your own risk.

I agree