Medical Questionnaire and Waiver

First name

Last name

Phone

Birthday

Day

Month

Year

Address

Are you currently suffering from a medical condition, illness, or injury?

Yes

Have you been hospitalized or concuss in the last 12 months?

Yes

If you answered yes to any question, please elaborate

Have any family members (including grandparents, parents and siblings) had any heart problems prior to the age of 60?

Have you ever had any injury, illness, back or joint conditions that may be aggravated by vigorous exercise?

Are you taking any prescribed medication?

Are you pregnant?

Do you have any diet requirement, allergy's or intolerances?

Do you have any other medical conditions that should be made known?

How did you hear about us?

I consent to Junior Lifters using media of myself and/or my children on their sites and for promotion*

I declare that the info I’ve provided is accurate & complete*

I am 18+ years or guardian of the child*

I want to subscribe to the newsletter

Nominated Business: Junior Lifters

Declaration and Waiver:

I realize that participation in exercise carries some risk. I hereby certify that I am aware of no medical conditions (except already noted herein) that may increase my risk of illness or injury due to an exercise program. I have read and understand this questionnaire and hereby exempt, release and discharge Junior Lifters, its servants, agents and contractors, from liability for any injury, illness or death as a result of my participation in any future program.
I realize nutritional advice given is general and I should consult my GP before making any changes to my diet.
I, the undersigned, in consideration of, and as a condition of, acceptance of my participation in the business's services, for myself, my heirs, my executors and administrators, waive all and any right or cause of action which I or they might otherwise have arising out of the loss of my life, or injury and damage, or loss of any description whatsoever which I may suffer.
This waiver release and discharge shall operate separately in favour of all persons, corporations and bodies involved or otherwise engaged in the operation of Junior Lifters, or servants or representatives of them.

Signature

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Date

Day

Month

Year