LIiablity Waiver

1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *

Yes

No

2. Do you feel pain in your chest when you do physical activity? *

Yes

No

3. In the past month, have you had chest pain when you were not doing physical activity? *

Yes

No

4. Do you lose your balance because of dizziness or lose consciousness? If yes, explain in detail: *

Yes

No

5. Do you have a bone or joint problem that could be made worse by physical activity? ___ *

Yes

No

6. Is your doctor presently prescribing drugs for your blood pressure or heart condition? *

Yes

No

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? *

Yes

No

8. Do you currently have or have you ever had any conditions or diseases in the past? *

Yes

No

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone

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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. *

I hereby declare that the information provided is true and correct

I agree to the terms and conditions of Limber Sports Performance

Date 1 *

MM

DD

YYYY