Aquatic Therapy Waiver Form

Aquatic Therapy Waiver Form
Complete this form before participating in aquatic therapy sessions so the provider has your contact details, safety information, and waiver acknowledgment.
Participant Information
Participant Full Name
First NameMiddle NameLast Name
Date of Birth
MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact and Therapy Background
Emergency Contact Name
First NameMiddle NameLast Name
Relationship to Participant
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Brief Therapy Background or Referral Notes
Current Health or Safety Concerns Affecting Aquatic Therapy
Other condition
Aquatic Therapy Waiver and Acknowledgment
Participant Signature
Powered by Jotform SignClear
Should be Empty: