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I {name} agree to abide by the rules of the Club, including the completion of the Pre-Activity Screening Questionnaire prior to the participation in any physical activities at the Club.  I further agree that all the use of the Clubs facilities, programs and services shall be undertaken at my sole risk and the Club and its employees shall not be held liable for any injuries, accident or participation in or use of, the Clubs facilities, programs and services.  I, for myself. and on behalf of my executors, its affiliates, officers, directors, agents or employees for all such claims, demands, injuries, damages or causes of action, including those resulting from the Clubs negligence, arising either directly or indirectly out of my participation in, or use of, the Clubs facilities, programs and services do not hold the Club accountable.

Pre- Activity Screening Questionnaire

1. Has your physician ever told you that you have a heart condition? 

2. Do you experience pain in your chest when you are physically active?

3. In the past month have you experienced chest pain when NOT performing physical activity?

4. Do you lose balance because of dizziness or do you ever lose consciousness?

5.Do you have a bone/joint problem that could be aggravated by a change of your level of physical       activity?

6. Is your physician currently prescribing medications for your Blood Pressure and/or Heart condition?

7. Do you know of any other reasons why you should not participate in a physical-activity program?

If you have answered yes to any of the questions above, it is RECOMMMENDED THAT YOU CONSULT WITH YOUR PHYSICIAN, before participating in a physical activity.

I declare that I have completed the Clubs Pre-Activity Screening Questionnaire and that I am physically able to participate in physical activity. Furthermore, I acknowledge that the Club has advised me to obtain a physicians'  clearance in the event the answers on the Pre-Activity Screening Questionnaire indicate that I should not participate in a program of physical activity  activity without a physicians clearance or if the Club is unsure of my physical health, yet that I maintain that I am physically capable of pursuing physical activity in the Club without such steps being taken or has done so.

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