Iron Tribe Fitness Waiver
Name
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Date
Weight
Pounds
Height
Inches
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Physical Activity Readiness
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
Do you feel pain in your chest when you do physical activity?
*
Yes
No
In the past month, have you had chest pain when you were not doing physical activity?
*
Yes
No
Do you lose your balance because of dizziness or do you ever lose consciousness?
*
Yes
No
Do you have a bone or joint problem (ex. neck, shoulder, back, knee, or hip) that could be made worse by a change in your physical activity?
*
Yes
No
Is your doctor currently prescribing drugs for your blood pressure, cholesterol, or heart condition?
*
Yes
No
Do you know of ANY OTHER REASON why you should not do physical activity?
*
Yes
No
If you answered YES to any of the above, please explain here:
Submit
Should be Empty: