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LIiablity Waiver


 

Diclosure of information

Please answer YES or NO to the questions below:

1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *
2. Do you feel pain in your chest when you do physical activity? *
3. In the past month, have you had chest pain when you were not doing physical activity? *
4. Do you lose your balance because of dizziness or lose consciousness? If yes, explain in detail: *
5. Do you have a bone or joint problem that could be made worse by physical activity? ___ *
6. Is your doctor presently prescribing drugs for your blood pressure or heart condition? *
7. Are you aware, through your own experience or a doctor’s advice other physical reason that would prohibit you from exercising without medical supervision? *
8. Do you currently have or have you ever had any conditions or diseases in the past? *
Name *
Name
Date of Birth *
Date of Birth
Phone
Phone
Please include number
CLIENT DECLARATION, hereby agree to the terms and conditions of Limber Sports Performance set out in this document. Being aware of my own health and physical condition, and having knowledge that my participation in any exercise program may be injurious to my health and involves a degree of risk, am voluntarily participating in physical activity with Limber Sports Performance. Having such knowledge, I hereby release JPS Health & Fitness their representatives, agents, and successors from liability for accidental injury or illness, which I may incur as a result of participating in the said physical activity. I hereby assume all risks connected therewith and consent to participate in said program. I agree to disclose any physical limitations, disabilities, ailments, or impairments, which may affect my ability to participate in said fitness program. *
Date 1 *
Date 1