Waiver and Liability Release Form
Name:________________________________ Home Phone Number: ____________________
Address:______________________________ Cell Phone Number:______________________
Email address: _________________________ Birthdate:______________________________
Is there any known reason why you should not participate in an exercise program? YES NO
If yes, explain:_________________________________________________________________
Have you had a physical examination by a physician in the last 12 months? YES NO
If no, when was your last physical? ___________________________________________________
Personal History: (circle the appropriate response)
High Blood Pressure YES NO
Shortness of Breath YES NO
Pregnant YES NO
Asthma YES NO
Medications YES NO
Smoking YES NO
High Cholesterol YES NO
Heart Arrhythmia YES NO
If YES to any of these above, please explain in detail: (use back if necessary):
Muscular-Skeletal History: (choose all that apply and describe on back if needed)
Surgery ______ (explain on back)
Rehabilitation/ Physical Therapy ______ (explain on back)
Back Pain __________
Knee Pain ____________
Neck Pain ____________
Any other physical limitations?
Many recreational activities and athletic programs involve substantial risks of bodily injury, property damage, and other dangers associated with participation in such activities. Dangers related to such activities include but are not limited to: broken bones, strains, bruises, concussion, heart attack, and heat exhaustion.
Each participant in such activities should realize that there are risks, hazards, and dangers inherent in such activities and in the training, preparation for, and travel to and from such activities. It is the sole responsibility of each participant to participate only in those activities for which he/she has the prerequisite skills, qualifications, preparations, and training.
The undersigned acknowledges that Faithful Workouts and (your name or facility name) will not be held responsible for any injury that occurs during a Faithful Workouts’ exercise session. All participation is at your own risk.
I acknowledge that I am solely responsible for any hospital or other costs arising out of any bodily injury or property damage sustained through my participation in this Faithful Workouts’ exercise session.