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Health Declaration

Please fill out the following health declaration form in order to participate in our activity. Submissions are valid up to 24 hours prior to the activity.

First name

Last name

Email

My body temperature is lower than 98.6°F/ 37.5°C

Are you experiencing any flu symptoms?

No

Yes

Date

Initials

I confirm that the information given in this form is true

Thanks for submitting!

Medical Questionnaire

Please fill out the following form to help us understand your physical condition.

First name

Email Address

Last name

Date of Birth

Have you been hospitalized in the last 12 months? *

No

Yes

Are you currently suffering from a medical condition, illness, or injury? *

No

Yes

If you answered yes to any question, please elaborate

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

VISIT

500 Terry Francois St.
San Francisco, CA 94158

CONTACT US

T: 123-456-7890

info@mysite.com

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