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Ripped Speed Fitness Medical Release Waiver

Medical Clearance History

PLEASE PRINT CLEARLY
Important considerations to consider before undertaking any type of exercise program are as follows:
Participant Name
Parent/s Name
Address
Home Phone #
City State Zip Email Address:

Gender
Male Emergency Name
DOB ____/____/_____
Female Phone #

Do you have any of the following:

Do you have any physical problems that are of concern to you? Yes No Are you on any medications? Yes No

Chest pain (during exercise and/or rest)? Yes No Coronary heart disease ? Yes No

Irregular heartbeats? Yes No Family history of heart disease? Yes No

High blood pressure? Yes No Are you pregnant? Yes No
Rheumatic fever? Yes No
Do You smoke? Yes No
Respiratory problems? Yes No
High cholesterol? Yes No
Chronic cough? Yes No
Dizziness or loss of consciousness? Yes No Shortness of breathe? Yes No
Seizures or convulsions? Yes No Diabetes? Yes No
Severe headaches? Yes No
Serious bone, joint, or muscle injury? Yes No Obesity? Yes No
Surgery(s) what, when? Yes No Arthritis? Yes No
Low back pain? Yes No
Do you have any medical condition not listed above that RSF should know about? Yes No

If you answered YES to any of the above questions, please explain.______________________________________________________

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CONSULT YOUR PHYSICIAN BEFORE BEGINING ANY EXERCISE PROGRAM
Waiver and Release

You (the client) agree that if you engage in any physical exercise, class, or activity, you do so at your own risk. You agree that you are voluntarily
participating in activities and assume all risks of injury or illness. You agree to release and discharge Ripped Speed Fitness from any and all claims
or causes of action (known or unknown) arising out of negligence. You acknowledge that you have carefully read this Waiver and Release and you
fully understand that it is a release of liability. You are waiving any right that you may have to bring legal action to assert a claim against Ripped
Speed Fitness for negligence.

Parent Or Legal Guardian: Date:

Participant:
HS8579
FORM RSF 2010003