Rummel Creek/Memorial Area Men's Boot Camp - Health and Waiver Form
Submitting waiver...
Email address *
Full Name *
Your answer
Address *
Your answer
Birth Date *
MM
/
DD
/
YYYY
Height *
Your answer
Weight *
Your answer
Do you have any of these: *
Required
If yes to any of the above, please describe:
Your answer
Are you on any Doctor restrictions that would restrict you from physical activity? *
Do you have any reasons why you should not do physical activity? *
Are you currently taking any medications? *
Do you have high blood pressure *
If yes to any above, please describe:
Your answer
Describe any surgeries which might limit your participation or activity?
Your answer
List any other health conditions or reason that could adversely affect you during physical exercise.
Your answer
Please note: If your health condition adversely changes, tell your exercise leader or health professional. Your health is solely your responsibility and your exercise leader or health professional cannot accept the responsibility for your health. *
Required
What is your goal for participating in Boot Camp? *
Your answer
Emergency Contact Name *
Your answer
Mobile Phone Number *
Your answer
Relationship? *
Your answer
Emergency Conact #2 *
Your answer
Mobile Phone Number *
Your answer
Relationship *
Your answer
Health Insurance Carrier
Your answer
Group Number *
Your answer
ID Number *
Your answer
Waiver & Liability Release
I HAVE READ, UNDERSTOOD AND COMPLETED THIS DOCUMENT TRUTHFULLY. ANY QUESTIONS I HAD WERE ANSWERED TO MY FULL SATISFACTION. I AGREE THAT THERE IS RISK TO ANY TYPE OF EXERCISE AND I ASSUME ALL RISK OF INJURY TO MYSELF OR DAMAGE TO MY PROPERTY AND I ACKNOWLEDGE THAT I AM SOLELY RESPONSIBLE FOR MY HEALTH. I, ON BEHALF OF MYSELF AND MY FAMILY, SUCCESSORS, SURVIVORS, HEIRS AND PERSONAL REPRESENTATIVES, UNCONDITIONALLY WAIVE, RELEASE AND DISCHARGE MY EXERCISE LEADERS AND ANY PERSON OR ENTITY ASSOCIATED THEREWITH, FROM ANY AND ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, COSTS, EXPENSES AND DAMAGES WHATSOEVER RESULTING FROM INJURIES SUSTAINED BY ME OR DAMAGE TO MY PROPERTY AS A RESULT OF MY PARTICIPATION IN THIS PHYSICAL FITNESS PROGRAM, INCLUDING, WITHOUT LIMITATION, THOSE RESULTING FROM ACTS OF ACTIVE, PASSIVE OR GROSS NEGLIGENCE.
Agreement to Participate *
Required
Date *
MM
/
DD
/
YYYY
Enter Your Name as your Signature
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service