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Health Declaration Form

Please fill out the following form in order to participate in physical activity.

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First Name

Email Address

Last Name

Date of Birth

Have you been hospitalized in the last 12 months?

No

Yes

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

No

Yes

If you answered yes to either question, please elaborate

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

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