WARNING - Form Has Not Been Signed - Please confirm this action
*Emergency contact Name: *Number
Your Exercise Past and Present
*Are you currently Exercising: Yes No
What are you doing:
*Have you exercised in the past: Yes No
What were you doing:
Health and Injury
Do you suffer from: (tick appropriate box)
*Any other conditions that may prevent you from safely exercising:
Are you Pregnant: In what trimester: 1st 2nd 3rd
Are you over 45?
*Have you had clearance from your doctor to exercise: Yes No
I, , have voluntarily chosen to participate in fitness activities offered by the office of Lift Performance Centre have answered the questions above to the best of my ability and affirm that my physical condition is good and I have no known conditions that would prevent me from participation. I acknowledge that participation is at my own pace and comfort level and that I may discontinue my participation at any time. Furthermore, I agree to self determine my exertion through good judgment and to discontinue any activity that exceeds my personal limitations. I understand that by signing this agreement that I hereby waive Lift Performance Centre, its Director, staff, and all relevant employees in any way from liabilities or demands as a result of injury, loss, or adverse health conditions as a result of my participation.
*I affirm that I have read and understand this document and I wish to participate in fitness activities.