Name *

First Name

Last Name

Phone *

Country

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Preferred Date *

MM

DD

YYYY

Date of birth *

MM

DD

YYYY

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

(###)

###

####

Have you had a physical in the last year? *

Yes

No

Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor? *

Yes

No

Do you feel pain in your chest when you do physical activity? *

Yes

No

In the past month, have you had chest pain when you were not doing physical activity? *

Yes

No

Have you ever experienced or had special needs in any of the following? (check all that apply and explain) *

Please check any that apply and explain each below in the text box

Abnormal resting EKG

Asthma/Lung disease

Anemia or bleeding/ clotting disorders

Attention/Anxiety Disorders (ADHD)

High cholesterol

Cancer

Diabetes

Eating disorders

Hip/pelvic pain or injury

Knee pain or injury

Lower back pain or injury

Neck/shoulder pain or injury

Seizures/Convulsions/Stroke

Thyroid conditions/problems

Heart Attack or Myocardial infarction

Hypertension/ High Blood Pressure

Flexibility Problems

Fear of heights or vertigo

Dizziness

Wears contacts

Hypo/Hyperglycemia

Current Pregnancy

COPD

Other

NONE

Do you suffer from depression? *

Yes

No

Are you experiencing any current health problems, under medical care, receiving mental behavioral services? *

Yes

No

Have you undergone surgery or experienced any injury, illness, allergy, or change in health status any time during the last year? *

Yes

No

Do you have any known allergies? (e.g. food, medicine, plants, animals/insects, other) *

Yes

No

Do you carry an epi-pen? *

Yes

No

Do you have any food allergies or aversions that we should be aware of? *

Yes

No

Do you have a contagious skin condition, or open sore or wound? *

Yes

No

Do you bruise easily? *

Yes

No

Do you have an artificial joint? *

Yes

No

Arrival Date *

MM

DD

YYYY

Arrival Time *

Hour

Minute

Second

AM PM

I agree to participate in Island Renewal Retreats at The Buccaneer Resort and Island Movement Wellness Center with their trainers and teachers. I recognize that exercise is not without varying degrees of risk to musculoskeletal and/or cardio respiratory Systems. I hereby certify that I know of no medical problems that would increase my risk of illness and injury as a result of participation in a fitness program designed by Island Renewal Retreats at The Buccaneer Resort and Island Movement Wellness Center. I understand and have been informed that there exists the possibility of adverse changes during the exercise program. I have been informed that these changes could include abnormal blood pressure, fainting, and disorder of heart rhythm, stroke, and very rare instances of heart attack or even death. I agree to waive, release, remise and discharge The Buccaneer Resort and its agents, officers, principals and employees; Island Movement and its agents, officers, principals and employees of any and all claims, demands, actions or damages of any kind resulting from participation in Island Renewal Retreats at The Buccaneer Resort and Island Movement Wellness Center classes or individual training sessions. The undersigned hereby releases The Buccaneer Resort and Island Movement Wellness Center as well as waives any and all claims and understands and assumes any and all risk with participation in Island Renewal Retreats at The Buccaneer Resort and Island Movement Wellness Center. *

Yes

No