Health declaration

Please fill out the following form.

First name

Last name

Email

Date of birth

Month

Day

Year

Have you been hospitalized in the last 12 months?

No

Yes

Are you suffering from a medical condition, illness or injury?

No

Yes

If you answered yes to any of the questions above, please supply additional information.

Have you been clear by your Healthcare Provider?

YES

NO

If you answered "NO" please select your approved start date.

Month

Day

Year

The participant agrees to personally and voluntarily assume all risks known and unknown asssociated with the activity. The particpant agrees to indemnify and hold Briana J. Reed harmless from any claims, injury, expenses, including lawyer fees arising from participants's actions or involvement.

Initials

The participant states they have read, understood, and signed the document voluntarily.

Signature

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I declare that the info I’ve provided is accurate and complete.