Health, Safety & Medical

First name

Last name

Emergency Contact

Emergency Phone

Have you ever suffered from:

Heart trouble and/or blood pressure problems?

Asthma, Bronchitis and /or shortness of breath?

Diabetes?

Epilepsy and/or fainting attacks?

Migraine?

Severe Head Injury?

Cancer?

Back Problems?

Allergies?

Fractures, Tendon, Ligament/Cartilage damage?

Physical or other disability?

Psychiatric or mental illness?

Have you been hospitalised within the last 2 years?

Are you suffering from or a carrier of any infectious diseases?

Are you registered as disabled?

Any other serious illness?

If you have answered yes to any questions above, please give further details below:

Do you regularly and/or currently use any form of medication?

Have you ever had an injury that forced you to stop exercising for more than a week?

Do you have any medical conditions that affect your breathing?

Do you have any conditions that affect your range of movement? Please specify where and how you are affected.

Do you know of any other reason that any physical or mental conditions may impair your ability to train?

Important – Please Read and Acknowledge

I certify that, to the best of my knowledge, my mental and physical health are satisfactory, and I have accurately disclosed my medical history and current condition. I understand that providing false information may compromise my safety.
I agree to promptly notify Summit Moor of any changes in my health status.
I acknowledge that running, coaching, and related physical activities involve inherent risks, including injury, illness, or death. I voluntarily assume all such risks associated with participation.
I confirm I have completed this health declaration honestly and that I am fit to participate.

Liability Waiver and Release of Responsibility

I hereby waive, release, and discharge Summit Moor, its coaches, staff, and affiliates from any claims, liabilities, or causes of action that may arise from my participation, except in cases of gross negligence or willful misconduct by Summit Moor.
By participating, I accept full responsibility for my safety and well-being and agree to participate at my own risk.

I have read, understood, and agree to the above waiver, liability disclaimer, and risk acknowledgment.

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.