Form

Full Name:*

Date:*

Please read the questions carefully and answer each one honestly: check YES or NO.

Has your doctor ever said that you have a heart condition?*

Yes No

Has your doctor ever told you that your blood pressure was too high?*

Yes No

Do you experience loss of balance due to dizziness or do you ever lose consciousness?*

Yes No

Do you have a bone or joint problem that is aggravated by physical activity?*

Yes No

Do you have high cholesterol?*

Yes No

Are you over 65 years of age and not accustomed to vigorous exercise?*

Yes No

Are you pregnant?*

Yes No

Do you know of any other reason that would not allow you to participate in a physical fitness program?*

Yes No

If YES explain:

I agree to the following User Agreement

In consideration of being allowed to participate in the activities and programs of (Lasting Looks By Lisa and PT On The Net) in addition to the payment of any fee or charge, I do hereby waive, release and forever discharge (Lasting Looks By Lisa and PT On The Net) and all others from any and all responsibilities or liability from injuries or damages resulting from my participation in any activities, or my use of equipment or machinery in the above mentioned activities. I do also hereby release all of those mentioned, and any others acting upon their behalf, from any responsibility or liability from any injury or damage to myself, including those caused by the negligent act or omission of any of those mentioned or others acting on their behalf, or in any way arising out of or connected with my participation in any activities.

I have read the above:*

I Agree

Physical Activity Readiness Questionnaire & Waiver of Liability