Medical Form - Like It Matters

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Medical Form

* Indicates required field

Class Dates *

Participant Name *

First

Last

Home Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Emergency Contact Name *

First

Last

Emergency Contact Relationship *

Emergency Contact Phone *

Gender *

Age *

Height *

Weight *

Family Physician *

Family Physician Phone *

Do you have any special dietary requirements? *

If you are a vegetarian, please specify in detail *

Smoking *

Smoking Non-smoker

Please Note: Our training is very intense and due to this our clients have incredible breakthroughs. There will be moments of emotional intensity and for this area we ask the follow questions:

Are you currently undergoing any psychological counseling? *

Yes No

If So, Date of Last Visit? (mm/dd/yyyy) *

If So, What Is The Reason For The Counseling? *

Do you suffer from any of the following chronic health issues? *

Neck, Back, or Shoulder Pain and/or Injury Option Diabetes, Seizures, or Frequent or Unexplained Fainting/Dizziness Chronic Illness or Physical Infirmity Pregnant Other

Please Briefly Describe Any Items You Have Checked Above: *

Statement of Personal Responsibility and Assumption of Risk

Disclaimer

Signature of Participant *

I have, to the best of my knowledge, completed the above Medical Evaluation Form with true and factual information. Further, I declare that I have not withheld any important and/or critical information from Like It Matters, LLC (LIM) and accept full responsibility for any and all information in the event that I have withheld important and/or critical information. Additionally, I accept sole responsibility to consult with my physician, if requested by LIM to verify that I have no physical and/or psychological problems, which would preclude me from participating in the course that I am currently enrolled in. If advised by either physician or LIM I shall complete any pre-conditioning programs prior to participating in said course. I agree to indemnify and hold harmless LIM, its agents, trainers, associates, and any other persons and/or entity involved in said course from any and all liabilities and claims arising from any physical and or/psychological harm sustained during the course. I accept full responsibility for all of my actions and therefore my safety during this course. I agree to comply with the instructions and/or direction of LIM and its staff during the course. Should my medical condition change, I agree to immediately notify LIM of the changes as it affects my ability to participate in the course.

Date (mm/dd/yyyy) *

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