Fitness Waiver and Health Information 2023 Form

  • Fitness Waiver & Health Information (2023)

  • Please answer the following questions to the best of your ability. All answers will be kept confidential.

  • Do you take any medications?
  • Do you have any allergies to food or medications?

  • Chronic Conditions:

     

     

  • Have you ever been told by a doctor or other health professional that you have any of the following conditions? (Mark all that apply)
  • Do you have a history of any of the following? Mark all that apply; if yes, not the year it began

  • Waiver

    Please check the following statements indicating your agreement with them. If you are unable or unwilling to agree to all of the statements, you will not be granted membership in the Whitney Fitness Center and will not be allowed to use the fitness equipment.

  • Date
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  • Should be Empty: