Health Form - Fitness By Tiger

Health

Name

Age

Cell Phone Number *

Email Address *

Street Address

Emergency Contact Info

Please check off and elaborate on any conditions that apply to you:

Muscle or skeletal pairvinjuries (flower back, neck, knee, shoulder):

Medications

Occupation/repetitive motions

Current physical activities/hobbies:

Please circle which intensity level fits the start of your program: Cautious. Weekend warrior. Athletic.

Goals (improve health, increase strength, tone, lose weight)

Long lasting motivation (grandkids, children, health scare)

Liability Waiver

I understand there is risk involved in participating in any exercise program. I am aware of my current medical/health condition(s). I agree to hold harmless and indemnify Lavonne Martin (nickname: Tiger Martin) from any and all liability arising out of participating in exercises and fitness programs, including but not limited to injury and loss or damage to my person. I am aware (that) Lavonne Martin does not provide medical or any other kind of insurance to participants. I also reconfirm that the information on the health history questionnaire is correct. I intend to be legally bound, do hereby for myself, my heirs, executors, and administrators, waive and release all rights and claims from damage I might accrue against Lavonne Martin, her personal representatives, assigns, heirs, and next of kin as well as landlord (Serop Aghyazian and and The S&L Trust) for any and all injuries.

Human/Owner Signature

Date