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Health Declaration Form
Name
Code
Select
Phone
Age
Gender
Address
Workshop you are registering for
Start date
End date
I agree to provide specific health details
Any Serious illness in the last three years:
*
Yes
No
Do you have any heart, spinal, endocrine, urinary or respiratory conditions?
*
Yes
No
Do you have any indication on bones such as Osteoporosis, Arthritis or any injury or surgery in the last 3 years?
*
Yes
No
Have you had or currently have hernia?
*
Yes
No
Do you have Glaucoma?
*
Yes
No
If any of the above is selected as Yes, please give details of the nature and duration of the condition and if you are currently undergoing any treatment
For women, Are you currently pregnant or planning for pregnancy?
*
Yes
No
I hereby willingly undertake to attend this program completely. I take full responsibility for the result and indemnify the organizers against all claims and suits. I will not communicate the contents of the program, either directly or indirectly to anyone else. I understand the participation guidelines and agree to follow them. I hereby declare that the above information is true, accurate and complete to the best of my knowledge.
Submit
Thanks for submitting!
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