first name:

last name:

hieght:
feetinches
wieght:
lbs
record:
winslosses draws
your email:

contact number:

medical insurance/care card #

Any chronic medical conditions? yes no
Ever had any surgery? yes no
Ever been hospitalized? yes no
Ever had a fracture or dislocation? yes no
Ever had a sprain or strain requiring special equipment or braces? yes no
Any vision problems? yes no
Do you wear contact lenses? yes no
Have you ever passed out while exercising? yes no
Have you ever felt dizzy while exercising? yes no
Have you ever felt chest pains exercising? yes no
Ever have wheezing or coughing while exercising? yes no
Have you been told you have high blood pressure? yes no
Ever feel as though your heart is skipping beats or irregular rhythm? yes no
Have you been told you have a heart murmur? yes no
Any family members die suddenly before the age of 50? yes no
Do you have a congenital defect such as single kidney, undecended testical, cardiac defect? yes no
Do you have any hernias? (groin or abdominal) yes no
Have you had a head injury or concussion? yes no
Have you ever been knocked unconscious? yes no
Have you ever had a pinched nerve or numbness or tingling in your arms hands or feet? yes no
Have you ever had heat stroke? yes no
Do you have any drug allergies? yes no
Do you have any medical conditions that might make participation in this event dangerous? yes no
if you answered yes to any questions please explain:

I DO DECLARE ALL INFORMATION TRUE TO THE BEST OF MY KNOWLEDGE.