SHKUA FITNESS

*Name:

*Address:

*City:

*State/Province:

*Gender:

Male Female

Height: example: 6-0 (6 feet 0 inch)

Weight:

*Birth Date: example: 01/31/71

Mobile Phone:

Home Phone:

*Email:

Contact Preference:

Physician's name:

Physician's phone:

Emergency contact name and relationship:

Emergency contact phone:

*Check all that apply:

Please list any medication and reasons for usage:

Please list any dietary and nutritional supplements and reason for usage:

Please list any surgeries:

List approximate age for each surgery

Are you involved in any sports or physical activities?:

List activities and how often

*I agree that all of the above information is true to the best of my knowledge.

By participating in various forms of exercise, I understand that there exists the remote possibility of adverse changes accruing during exercise including, but not limited to, abnormal blood pressure, fainting, dizziness, disorders of heart rhythm, and very rare instances of heart attack, stroke, or even death. I further understand that there exists the risk of bodily injury including, but not limited to, injuries to the muscles, ligaments, tendons and joints of the body. I fully understand the risk of bodily injury, heart attack, stroke, or even death, but knowing theses risks, it is my desire to participate in various guided exercise activities and hold harmless, SHKUA LLC, instructors and affiliates.

I Agree

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