UNBOUNDED PARTICIPANT WAIVER

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Intake, Waiver and Content Consent

Email *

Please Select Session *

Unbounded Cold Camp

Unbounded Facilitator Training at Cold Camp

Other:

Required

Please Select Date *

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Name *

Date of Birth: *

YYYY

Address: *

Phone Number: *

Emergency Contact Information: [Address, Email, Phone & Relationship] *

Do you suffer from any of the following conditions? *

Hypertension or High Blood Pressure, Hypotension or Low Blood Pressure

Is there anything else Team Unbounded Facilitators should know about?

Raynaud's Condition in Body, Hands, or Feet

Pregnant or Chances of Pregnancy

Allergies to Cold or Hot

Heart Conditions or Diseases

Kidney Failure

Epilepsy

Recent Surgery

Migraine

None of the Above

Other:

Required

If you have any contraindications I agree to disclose to Unbounded Well *

I agree and DO have contraindications

I agree and do NOT have no contraindications

Do you currently take any medications? If so, please disclose.

Do you have any existing allergies? If so, please disclose.

Auto-Immune Diseases; rheumatism, MS, Crohn, Diabetes, Asthma, other?

Please disclose any additional health related concerns.

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