Participant information

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Section A: Registration Information

First & Last Name *

Date of Birth *

YYYY

Street Address *

City *

Email *

Phone

Section B: Emergency Information

Emergency contact #1: First & Last Name *

Emergency contact #1: Relationship *

Emergency contact #1: Phone Number *

Emergency contact #2: First & Last Name

Emergency contact #2: Relationship

Emergency contact #2: Phone Number

Family doctor Name

Family doctor Phone Number

Important medical considerations (allergies, medications)

Can you administer your own medication(s)?

Yes

Clear selection

Terms and conditions

Consent *

The applicant hereby agrees to observe all rules and regulations established for maintaining order and protecting members from injury, and to respect the discipline of the instructors. In consideration of acceptance of this entry, I for myself, my executors, administrators and assigns, do hereby release and discharge Fitness Dynamics from all claims and damages, demands and actions whatsoever in any manner arising or growing out of my participation in this program. I attest and verify that I have full knowledge of the risks involved in this program and I am physically fit and sufficiently trained to participate.

Click here to indicate that you have read and agree to the terms and conditions presented in the Consent section

Required

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Fitness Dynamics.

Does this form look suspicious? Report

Forms