Health Form

ABOUT YOU

Name *
Name
Birthday
Birthday
Phone
Phone
Address
Address
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Number *
Emergency Contact Number

Help me serve you better

(If the answer is no please skip to question 4)
Do you suffer from any of the following health issues? Check where applicable.
Are you ok with use of the following?

Please be aware that proper care shall be taken for your well-being and safety, however, it is important to realize it is ultimately your responsibility to adjust your practice to avoid injury. No responsibility can be taken for injuries from, or as a consequence of, your participation in these classes.

Date
Date