WAIVER AND RELEASE FORM

First Name:
Last Name:

Gender:    -- Choose -- Male Female

Date of Birth:
Height:
Weight:
Home Phone:
Work Phone:
Mobile Phone:
Email Address:

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Test Date/Time:
Referred By:

Please read and sign this form prior to taking part in the Hoffacker Health and Fitness Accelerated Program.

Have you ever been diagnosed with a heart condition or advised to avoid physical activity not recommended by a doctor?:	-- Choose -- Yes No
Do you feel pain in your chest when you do physical activity?:	-- Choose -- Yes No
During the past month, have you had chest pain when you have NOT been doing physical activity?:	-- Choose -- Yes No
Do you currently take any prescribed drugs for blood pressure or a heart condition?:	-- Choose -- Yes No
Do you wear a pacemaker?:	-- Choose -- Yes No
Do you lose your balance due to dizziness or ever lose consciousness?:	-- Choose -- Yes No
Have you ever been diagnosed with cancer and/or had a tumor removed?:	-- Choose -- Yes No
Do you have a bone of joint problem or condition that could be made worse by a change in your physical activity?:	-- Choose -- Yes No
Have you had a recent hip or knee replacement?:	-- Choose -- Yes No
Have you had any of the following fitted recently? (IUD Coil, Metal pins, Metal bolts, Metal plates):	-- Choose -- Yes No
Are you currently pregnant or have you given birth less than 6 weeks ago?:	-- Choose -- Yes No
Have you had surgery or suffered an injury requiring medical attention in the past 6 weeks?:	-- Choose -- Yes No
Do you suffer from any of the following conditions? (Epilepsy, Severe Diabetes, Severe migraine, Detached retina)	-- Choose -- Yes No
Do you know of any other reason why you should not do physical activity?:	-- Choose -- Yes No

RISKS AND DISCOMPFORTS OF TRAINING SESSIONS

Risks and discomforts of training sessions The reaction of the body to such activities cannot always be predicted. There exists the risk of certain changes occurring during or following exercises; these include abnormalities of blood pressure, heart rate or, in rare instances, cardiac complications. Should you feel unwell, please let your Conditioning Specialist know immediately. Every effort will be made to avoid any adverse reaction. A doctor will not be present during the sessions.

I understand that my participation in the Accelerated Program involves inherent risks that could cause injury to me. There may be other risks not known or reasonably foreseeable at this time. I have considered these risks and I voluntarily choose to assume all risks of injury. I assume full responsibility and agree to release, hold harmless and indemnify to the fullest extent permitted by law, Hoffacker Health and Fitness from all liabilities, claims and damages arising out of any issues that may arise.

I, the undersigned, being over the age of 18 years, hereby acknowledge my consent to voluntarily participate in the Hoffacker Health & Fitness Accelerated Program. I am aware of my own physical condition and physical limitations and represent that I am in sound health and able to willingly engage in this program. I agree that I will immediately contact a physician if I am in need of any medical care. I also agree to convey to a Hoffacker representative before, during, and after each conditioning session, any information related to my health, physical condition and physical limitations which may effect or be effected by my participation in the Program. I have read this Waiver and Release and fully understand its terms. I sign this Waiver and Release freely and voluntarily, without any inducement or coercion.