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Health Declaration Form

A calm registration experience, one step at a time.

Step 1 of 7 14%

1) Personal Information

Full Name

ID Number

Date of Birth

Phone

2) Emergency Contact

Name

Phone

Relationship

3) Health Status

Do you have chronic conditions?

No Yes

Allergies

Current Medications

4) Injuries and Fitness

Current Injuries

Previous Fractures

Surgeries

Physical Activity Level

5) Mobility and Cardio

Back / Neck / Knee Pain

Heart Issues

Breathing Issues / Dizziness

6) Notes + Consent

Additional Notes

I confirm the information is accurate I understand this retreat includes physical activity I consent to first aid if needed I agree to photos/video during the retreat

7) Signature

Signature Method

✓

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