Virtual AOF Physical Activity Waiver | serecocampbell

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CLIENT PARTICIPATION, HEALTH & LIABILITY WAIVER

To register please fill out the following medical form

First Name

Email Address

Last Name

Date of Birth

Whe was your last physical with your physician?

Phone

Have yophyiscal reason against your exercising without medical supervision?ver be diagnosed with a heart condition, and or any chronic illness /disease? *

No

Yes

Not sure

Are you suffering from any pain in or around your joint structures? *

No

Yes

Initials

I declare that the info I’ve provided is accurate & complete

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