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)

Arthritis_______ 

Osteoporosis __________ 

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.

 

Signature_________________________________________________

 

Date_____________________________________________________

 

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