Name *

First Name

Last Name

Phone Number *

(###)

###

####

Do you have any illnesses or injuries that we should be aware of?

Yes

No

I declare that to the best of my knowledge the information given above is correct and that I am unaware of any reason why I should not participate in any form of physical activity. I agree that it is my decision to enter into exercise entirely at my own risk and I waive any legal recourse for damages to myself which may arise from my participation in physical activity.

Yes