Sample Physical Activity Waiver
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Company
Name:___________________________________________________________
Company
Address:_________________________________________________________
Employee Participant Name:
_________________________________
Dept.:___________________
Date of Birth:
_______________ Emergency Contact: ____________________________
During your exercise
program, at the above company location, every effort will be made to assure your
safety. However, as with any exercise program, there are risks, including
increased heart stress and the chance of musculoskeletal injuries. In
volunteering to participate in this exercise opportunity, you agree that, to
your knowledge, you have no limiting physical conditions or disability that
would preclude an exercise program.
A physicians
examination is recommended for all participants with any exercise restrictions,
including any heart problems, high blood pressure, chest pain dizziness,
relevant surgeries, diabetes, asthma, epilepsy, arthritis, or significant injury
to any part of the body. By signing below, you accept full responsibility for
your own health and well-being and you acknowledge an understanding that no
responsibility is assumed by the company listed above or any other related
agency.
The above company and
other related agencies are released from any liability now or in the future for
conditions that may result from participation in any on-site exercise program
including but not limited to: heat attacks, muscle strains, muscle pulls, muscle
tears, broken bones, shin splints, heat exhaustion, injuries to knees, injuries
to back, injuries to feet, or any other illness or soreness that may occur,
including death.
I hereby affirm that I
have read and fully understand the above statements.
_____________________________ _________________
Employee Participant
Signature Date