PAR-Q WAIVER AND RELEASE

Name
Email
Date of Birth
Phone
Address
Referred By
City
State
Zip Code
Occupation
Gender Male Female
In Case of Emergency Notify the Following Person (Name, Relation, Address, Number)
Please check the following boxes if you could answer YES to any of the following statements:
If your doctor has ever said you have heart trouble.
If you frequently suffer from chest pain.
If you often feel faint or have spells of severe dizziness.
If your doctor has ever said that your blood pressure is too high.
If your doctor has said that you have a bone or joint problem (ex.
      arthritis) that has been aggravated by exercise or made worse by
      exercise.

If there is a good physical reason not mentioned here why you should
      not follow an activity program even if you wanted to.

If you are a male over 40 years of age or a female over age 50.
If you have suffered from a heart attack.
If you often have difficulty breathing.
If you ever experience an irregular or racing heart rate during
      exercise or at rest.

If you are diabetic.
If you are pregnant.
Warning:
If you answer YES to ANY questions on the PAR-Q section of this questionnaire, you MUST consult with a physician before you begin your exercise program and George Guerin reserves the right to request written verification from your doctor before you begin your training.
Signature (ex. /John J. Doe/)
Printed Signature (ex. John J. Doe)
Authorized By
Today"s Date