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FIT VENTURES PROGRAM PARTICIPATION WAIVER/RELEASE

PARTICIPANT’S NAME______________________________________________

PHONE (H)__________________________ (Cell)_________________________

ADDRESS

___________________________________________________________

AGE

DOB

Gender: M

F

_______

____________________

I have volunteered to participate in a program of progressive physical exercise. I waive any possibility of personal damage which may be blamed upon such a program in the future, and I accept full responsibility for requesting such exercise and assistance. The possibility of certain unusual changes during exercise does exist. They can include: abnormal blood pressure, fainting, disorders of heartbeat, and in very rare instances heart attack. Every effort will be made to minimize any such unusual changes by preliminary examination and by observations during situations which may arise. I hereby acknowledge and accept these risks. To my knowledge, I do not have any limiting physical condition or disability which would preclude an exercise program.

______________________________________ ______________________

Participant’s Signature

Date

It is highly recommended that a physician’s examination be obtained by all participants prior to involvement in an exercise program.

have been informed of the need for a I , _____________________________________, physician’s approval for participation in a progressive exercise-fitness program. I fully understand the physical nature of the program.

I accept complete responsibility for my health and well being in this voluntary exercise- fitness program, and I understand that no responsibility is assumed by either Fit Ventures’ staff, or by any staff of the cooperating agencies.

_______________________________________ _______________________________

Participant’s Signature

Date

Venture Name

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ D a t e ( s ) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Staff Name

_______________________

Staff Signature

_________________________

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