Health Declaration

&

Waiver

Please fill out the following form
in order to participate in our activity.

First Name

Last Name

Date of Birth

Have you been hospitalized in the last 12 months?

Yes

Are you suffering from a medical condition, illness, or injury?

Yes

If you answered yes to any question, please elaborate

Initials

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!

Health Declaration & Waiver

Health Declaration

&

Waiver