If participants is between ages 12-17, parent information is required.

This health history form is intended to obtain relevant information about your health that will assist the staff in helping you with your program. Please answer all questions to the best of your knowledge.

Questions Yes No
Do you have any reason to believe you should not exercise?
Were you a high school and/or college athlete?
Questions 1 2 3 4 5
Do you have any negative feelings toward or have you had any bad experience with fitness testing and evaluation?
Do you start exercise programs but then find yourself unable to stick with them?
Questions 1 2 3 4 5
Are you currently involved in regular cardiovascular exercise?
Questions Light Fairly LIght Somewhat Hard Hard
Questions Yes No
Questions Yes No
Questions 1 2 3 4 5 6 7 8 9 10

I hereby certify that I or my teen is in normal health and capable of safe participation in the program in which I or he/she am enrolling.

I understand that the program will involve a certain degree of strenuous physical activity. I agree to assume all risks associated with the program and further agree to hold the YMCA harmless from and against any and all liability, loss, claims, costs and expenses, for both personal injury and/or property damage, including attorney fees, which may arise as a result of my participation in the YMCA Strength Training Programs.

In the event of an emergency, and emergency contact cannot be reached, I hereby authorize the YMCA to obtain medical treatment for myself or my teen at my expense.

Sign above