Health Declaration Form

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Empowering You Through Dance and Movement

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Health Declaration Form

Please fill out the following health declaration form in order to participate in our activity.

Full Name

Date

Please tick if you have ever experienced the following:

Diabetes

Chest pain brought on by physical exertion

Epilepsy

Dizziness or Fainting

A bone, joint, or muscular problem or arthritis

Asthma or other respiratory problems

Any sustained injuries or illnesses

Any allergies e.g metal, medication, skin allergies etc

Are you taking any medication

Family history of heart problems

Have been admitted in hospital over the last 6 months

None of the above

Are you pregnant or have been in the last 6 months?

Yes

Is there any reason not mentioned above why any type of physical activity may not be suitable for you?

Yes

I understand that:

Bruises may occur due to the nature of the fitness

For my safety, physical spotting will occur during the classes

If the instructor requires further information about my illness or disability to be included in the activities, I will endeavour to make sure this information is available to him/her.

Pictures may be taken by the instructor during the class for social media purposes

By checkng this box, I acknowledge that I have read and agree to the Terms and Conditions

By checking this box, I affirm that I agree to the Release and Waiver of Liability

Thanks for submitting!

2nd Floor, Blue 7 Building, Jalan Penampang Baru, 89500 Kota Kinabalu, Sabah, Malaysia

+6 (011) 16207653

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