Official Registration Form

General Information

Full name: {name}

Date of Birth: {dob}

Address: {address}

Phone Number: {phone}

Emergency contact name: {contact_name}

Emergency contact relationship: {contact_relation}

Emergency contact phone number: {contact_phone}

Physical Readiness Questionare

Please check the box for all conditions which apply:

Has a doctor ever said you have heart trouble?

Do you frequently have pains in your heart or chest?

Do you often feel faint or have spells of severe dizziness?

Has a doctor ever said your blood pressure was high?

Has a doctor ever told you that you have a bone or joint problem that has been aggravated by exercise or might be worsened through exercise?

Is there any reason not mentioned here why you should not follow an activity program even if you wanted to?

Are you over 65 and not accustomed to vigorous exercise?

If you answered yes to one or more of the questions above, please consult with your personal
physician before increasing your physical activity. Tell your physician which question(s) you
answered "yes" to. After medical evaluation, seek advice from your physician as to your suitability
for unrestricted physical activity starting off easily & progressing gradually.

Note: This physical activity clearance is valid for a maximum of 12 months from the date of completion and becomes invalid if your condition changes so that you answer YES to any of the above question

Release From Liability

I have completed the above questionnaire accurately, listing all health problems known to me. I understand there are certain inherent risks associated with participation in your program. I exempt from liability, NESF LLC, its owners, & employees for any injuries that I may incur while participating in the program.

Date: {sign_date}