Team Survivor San Diego

Information Form

First name

Last name

Phone

Birthday

Month

Day

Year

Address

Cancer Type

How did you find us?

Emergency Contact Name

Emergency Contact Number

Which program(s) are you interested in?

Dragon Boating

Yoga

Online Fitness

Do you have a heart condition that affects your physical activity?

Yes

Do you feel chest pain when you do physical activity?

Yes

Do you ever lose your balance or become dizzy?

Yes

Have you ever lost consciousness?

Yes

Do you have a bone or joint problem that could be affected negatively by physical activity?

Yes

Are you taking blood pressure or heart medications?

Yes

Are you pregnant or have you given birth in the past 6 months?

Yes

Have you had recent surgery?

Yes

Have you had any problems since last cancer treatment or surgery?

Yes

Is there any reason why you should restrict your physical activity?

Yes

Please explain any “Yes” answers above

Previous exercise

A lot

Some

Not really

Never

For Dragon Boat only – do you have basic swimming skills?

Yes

What are your fitness interests and goals?

The undersigned is under the care of a medical professional and has been asked to obtain a Medical Release before program participation.

I assume all responsibility for and risk of damage or injury that may occur in any programs organized by Team Survivor, including injuries occurring while participating in exercise or movement or wile using equipment or facilities. In consideration of being a participant in programs I, or on behalf of myself and my heirs or assigns, hereby release and discharge Team Survivor, its officers, directors, employees, agents and volunteers from all claims, demands, rights of cause of action, present or future, whether known or unknown, anticipated or unanticipated, and resulting from or arising out of incident to my participation in programs.

I have read and understand this assumption of risk agreement and release and willingly and without duress sign it, on behalf of myself and my spouse/partner with his/her full consent and approval, and agree to be bound by it.

Signature (parent/guardian if under 18 years old)

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