Medical Waiver Form

  • DD slash MM slash YYYY

    I understand and do hereby consent to participate in a fitness training program that will include stretching, cardiovascular and strength training exercises. I have been informed and understand that physical exercise has been associated with certain risks, including but not limited to occasional minor injuries (e.g. pulled muscles, muscle soreness, muscle-skeletal strains and sprains, bruises) to infrequent serious injury (e.g. heart attack, stroke or other cardiovascular accidents, muscle tears) to the very rare catastrophic incident (e.g. death, paralysis). I acknowledge that regardless of the care taken, Jo Stephens Fitness Ltd cannot guarantee my personal safety. In the case that I have disclosed any medical conditions such as elevated blood pressure, back pain or any other medical condition that may increase my risk, I take full responsibility and will take part at my own risk.


    I understand it is my responsibility to

    1. fully disclose any health issues (including diabetes, heart problems, seizures, or asthma) or medications that are relevant to participation in a strenuous exercise program;
    2. inform the instructor or trainer if there are any changes to my health, including injuries and sickness; .
    3. inform the instructor or trainer if there are activities with which I do not feel comfortable;
    4. cease exercise and report promptly any unusual feelings (e.g., chest or other discomfort, nausea, difficulty breathing, injury) during the exercise program; and
    5. clear my participation with my doctor.

    In agreeing to this exercise program, I, the participant

    1. acknowledge that my self-participation is completely voluntary;
    2. understand the potential physical risks involved in the exercise program, and believe that the potential benefits outweigh those risks;
    3. give consent to certain physical touching that may be necessary to ensure proper technique and body alignment;
    4. understand that the achievement of health or fitness goals cannot be guaranteed;
    5. have been able to ask questions regarding any concerns I might have, and have had all questions answered to my satisfaction;
    6. am in good physical condition, have no impairment which might prevent my participation in such activities, and have been advised to consult a physician prior to beginning this program;
    7. have been advised to cease exercise immediately if I experience unusual discomfort and feel the need to stop.

    By signing below on the date first mentioned above, I acknowledge and agree that I have read the foregoing and know of the nature of the activities and I agree to all the terms of this agreement.