deliberate Cold Exposure workshop - with certified instructor Gemma Douglas.

HEALTH DECLARATION / Personal Liability Statement & Health Certificate.

Name

First Name

Last Name

Date of Birth:

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Questions regarding your overall health. Are you currently healthy?

Do or did you suffer from one of the following conditions?

Heart disease

Serious hypertension

Epilepsy

Kidney failure

Serious asthma

Recently performed surgery

Migraine

Do you have an auto-immune disease?

Such as rheumatism, MS, crohn, diabetes, if so which?

Any other health conditions?

Please make sure you declare all health conditions. This information is confidential and for your safety.

Do you currently take any medication?

Please write down what medication you take, especially any heart medication.

Are you allergic to a certain substance?

Food / Environment etc.

Are you currently pregnant or do you wish to become pregnant?

Is there anything else your practitioner should know about?

Personal Liability Statement and Health Certificate: Deliberate Cold Exposure Workshop

Personal Liability Statement & Health Certificate Deliberate Cold Therapy workshop As Gemma Douglas, I see to it that the Deliberate Cold Exposure activities are carried out safely and correctly. However, I cannot assess the health risks particular to individual participants. Participants are notified about the health risks in advance via a written statement. I point to their personal responsibility, and advise to consult their personal physician/doctor should the medical questionnaire prompt any potential issues. It is ultimately up to the participant to determine whether they are fit to take part. PERSONAL LIABILITY STATEMENT "I hereby declare that I participate in the activity on *date* voluntarily and entirely at my own risk. I shall not hold *name instructor* liable for any damages and/or injury resulting from participation in the *activity*’’. HEALTH DECLARATION "I hereby declare that I have been adequately informed about the particulars of the Deliberate Cold Exposure activity beforehand, and that I am in good physical and mental condition. I shall not hold Gemma Douglas liable for any damages and/or injury resulting from participation in the Deliberate Cold Exposure Workshop. My participation is entirely at my own risk". IN CASE OF AN EMERGENCY - PLEASE CALL:

I hereby declare to have filled out this form truthfully.

Yes

Today's Date:

YYYY

Digital Signature:

Please write your name in the text box as an electronic signature. Any other queries please email Gemma at gemma@themotherhoodproject.co.nz