HEALTH INFORMATION &
HOLD HARMLESS AGREEMENT
Should be completed and updated annually by anyone participating in the department’s exercise programs (Stretch & Tone, Aquaerobics, etc.)
Name:______________________________________________________________________________ Date: ________________
Age: __________ Gender: M F Home Phone: ______________________ Cell Phone: ________________________
What is the present state of your general health? Good Average Poor
Physician’s Name: _______________________________________________ Physician’s Phone: ________________________
Person to contact in an emergency: _______________________________ Phone: __________________________________
Please list all medications that you presently take:_____________________________________________________________
__________________________________________________________________________________________________________
Are you now or have you been pregnant within the past three months? Yes No
Does your physician know that you are participating in an exercise program? Yes No
DO YOU NOW OR HAVE YOU HAD WITHIN THE PAST YEAR:
1. History of heart problems? Yes No
2. High blood pressure? Yes No
3.Difcultywithphysicalexercise? Yes No
4. A chronic illness? Yes No
5. Advice from a physician not to exercise? Yes No
6. Disorder that is aggravated by exercise? Yes No
7. Recent surgery (within past 3 months)? Yes No
8. History of lung problems? Yes No
9. History or diabetes? Yes No
10. Smoking habit? Yes No
11. High blood cholesterol? Yes No
I have carefully reviewed the health information above and attest to its accuracy. I also understand that I may be asked
by the instructor or the Parks & Recreation Department to provide a physician’s note before participating!
The undersigned hereby agrees to indemnify, save harmless, and waives liability of the Town of Queensbury, the Town Board, and Parks & Recreation
Department, employees and volunteers thereof, for any responsibility should an accident or injury occur to the undersigned participant as a result of
participation in any program sponsored by the Queensbury Parks & Recreation Department or while using recreation program facilities.
______________________________________________________ ____________________________
Signature of Participant Date
742 Bay Road, Queensbury NY 12804
(518) 761-8216 • recreation.queensbury.net
