EmailMe Form - Physical Activity Readiness

Date Time *

MM / DD / YYYY

Name *

Age *

Gender *

Email *

Phone *

### - ### - ####

Sport *

Days/times available to train? *

Regular exercise beneficial to the health in general. However, one must be careful about any associated injury risk. Please fill out the following form carefully so that program can be properly planned. please answer Yes or No:

Choose Yes or No

	Yes	No
1. Do you have any condition that would limit you from any form of physical activity?	1	2
2. When you do perform any form of physical activity do you feel any discomfort?	1	2
3. Do you ever lose your balance or feel dizzy?	1	2
4. Do you have a joint or bone problem that may get worse due to physical activity?	1	2
5. Do you take any form of medication?	1	2
6. Do you have insulin dependant diabetes?	1	2
7. Do you know of any other reason due to which you should not exercise or increase your physical activity?	1	2

Note: If there are any changes in your physical health which can make you change your answer to any of the above questions to YES, please make it known to your personal trainer.

I have read, fully understood, and completed the above questionnaire honestly and to the best of my ability. I understand that I will going through a strenuous physical training routine during which I could get injured. I am voluntarily participating in this training program and take full responsibility for any risk of injury that might result. I agree to waive any claim or right to sue Elite Youth Training or instructor thereof.

Athletes Signature: *

Date: *

Parent/
Guardian Signature: *

Date: *