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Park in the Fall

Waiver

Once you have booked your service with Athletes Empowered, please fill out a waiver for each participant.

Athletes Empowered Participation Waiver

Please fill out the following form
in order to participate in our session.

First name

Last name

Email

Date of birth

Phone

Group name

Have you recently had a concussion? If so, when? *

No

Yes

Do you have any medical conditions, illnesses, or injuries? *

No

Yes

Do you have any of the following? *

Arthritis

High blood pressure

Cognitive dysfunction

Cancer

Diabetes (Type I or II)

Kidney Disease

Other Chronic Health Concerns

None

Has you doctor told you to avoid exercise? *

No

Yes

If you answered yes to any question, please elaborate:

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

I acknowledge that the services offered by Athletes Empowered do not provide diagnostic information.

I acknowledge that I am an expert on my body and I will listen to what it needs during testing/screening and will stop if I need to.

I acknowledge that I can withdraw my consent and participation at any time.

I release Athletes Empowered from responsibility of injuries or accidents that may occur during participation in testing and screening.

Payment is due 24 hours in advance.

Signature of participant or guardian

Thanks for submitting!

Athletes Empowered is based out of Whitchurch-Stouffville, Ontario.

We travel to you.

info@athletesempowered.net

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