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Guest Orientation & Liability Waiver
If you are a guest of a patron and are new to the SBTS Health & Rec Center please fill out the information below.
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* Indicates required question
Today's Date
*
MM
/
DD
/
YYYY
Host Full Name
*
Your answer
Host Email Address
*
Your answer
Host Student ID#
*
Your answer
Guest Full Name
*
Your answer
Guest Gender
*
Male
Female
Guest Age
*
Your answer
Guest Phone Number | (xxx)xxx-xxxx
*
Your answer
Emergency Contact Name
*
Your answer
Emergency Contact Number | (xxx)xxx-xxxx
*
Your answer
What is the present state of your general health?
*
Choose
Poor
Fair
Excellent
Check if you now or have had the following issues:
*
Heart Problems
High Blood Pressure
Chronic Illness
Lung Problems
Diabetes
High Blood Cholesterol
Muscle, joint, or back Issues aggravated by physical activity
None of the above
Other:
Required
Has your physician advised you not to participate in physical activity?
*
Yes
No
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