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& PRE SCREEN
Date of Birth
Family history of heart disease?
Do you smoke?
Do you have high blood pressure?
Are you taking medication
Do you have or had any injuries we should know about
Do you regurly exercise?
Please specify anything we should know about
I declare that the info I’ve provided is accurate & complete
I hereby acknowledge this release from liability for accidental injury or illness which I may incur as a result of participating in any physical activity. I hereby assume all risks connected therewith and consent to participate in this program. I agree to disclose my physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in this program.
Thanks for submitting!
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