paperwork+-2

=Liability release-need you to print, sign and return=

0 row selected - rows selected - [|clear] [|Refresh] || INDIVIDUAL APPLICATION AND LIABILITY RELEASE Regular physical activity is safe for most people. However, some individuals should check with their physician before they start an exercise program. To help determine if you should consult with your doctor before starting to exercise, please read the following questions carefully and answer each one honestly. All information will be kept confidential. YES or NO (please check):  x Has your doctor ever said you have a heart condition and that you should only do physical recommended by a doctor? no  x Do you feel pain in your chest when you do physical activity? no  x In the past month, have you had chest pain when you were not doing physical activity? no   xDo you lose your balance because of dizziness or do you ever lose consciousness? no   xDo you have a bone or joint problem that could be made worse by a change in physical activity? no (just increasing walking will be good for my bum knee, not bad)   xIs your doctor currently prescribing drugs for a heart condition or that affects your blood pressure? no  x Do you know of any other reason why you should not increase your physical activity? no If you answered YES to one or more questions: Talk with you doctor by phone or in person BEFORE you start becoming much more active. Tell your doctor about this questionnaire and which questions you answered yes. You may be able to do any activity you want – as long as you start slowly and build up gradually. Or you may need to restrict your activities to those that are safe you. If you answered NO to one or more questions: If you answered NO honestly to all questions, you can be reasonably sure that you can start becoming more physically active – begin slowly and build up gradually. I understand that any exercise program I undertake may create physical stress and subsequent harmful effects. I agree that it is solely my responsibility and not the responsibility of [YOUR Company] to require me to consult with a physician prior to commencing any exercise program, to remain under medical supervision if that is indicated, and to seek medical assistance in the event of an injury. I recognize that the use of the equipment entails some risk of accidental injury to myself and to others and I agree that I will use such equipment and facilities with due care. Name: Melinda D Colver __Date: Dec 8, 2011__ Telephone: (715 __)__ 274_ 7777 _ Age:56 __Gender:__ __Male__ _ Female x Signature: __Melinda D. Colver_ ||
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 * [[image:http://www.wikispaces.com/i/user_none_lg.jpg caption="kruzer" link="http://www.wikispaces.com/user/view/kruzer"]] || [|kruzer] Nov 19, 2011 6:40 am