Waiver form

Waiver form:

Before attending one of my classes, please make sure that you have filled out the form below.

Full name:

E-mail address:

Date of birth:

Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?

Yes No

Do you feel pain in your chest when performing physical activity?

Yes No

Have you experienced chest pain when NOT performing physical activity in the last month?

Yes No

Do you lose your balance because of dizziness or have you lost consciousness recently?

Yes No

Do you have any bone or joint problems such as arthritis, which could be aggravated through physical activity?

Yes No

Is your doctor currently prescribing you medications for high blood pressure or a heart condition?

Yes No

Have you had an operation in the last 12 months?

Yes No

Is there any other reason why you should NOT participate in physical activity?

Yes No

I accept that I am voluntarily engaging in an acceptable level of exercise, and that my participation still involves a risk of injury.

I accept I do not accept