Health Waiver
Please take a minute to fill in the following info. Updated forms required to participate in Peak in-person and virtual training services.
First Name
Last Name
If minor, parent/guardian name
Emergency Contact Name
Emergency Contact Phone Number
Birthdate
Email
Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?
Yes
No
Do you feel pain in your chest when you perform physical activity?
Yes
No
In the past month, have you had chest pain when you were not performing any 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 that could be made worse by a change in your physical activity?
Yes
No
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?
Yes
No
Do you know of any other reason why you should not engage in physical activity?
Yes
No
If you answered Yes to any of the above questions, please attach a medical clearance from your health care provider to begin a physical fitness program.
Select a File
I agree to the Release of Liability found here: https://www.startwithpeak.com/policies
Your Signature
*
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