Emergency Contact & Medical Disclosure Form

(Gym / Studio Name)

Facility Address:

1. Member Information

Full Name:

Date of Birth:

Phone:

Email:

Address:

2. Primary Emergency Contact

Name:

Relationship:

Phone (primary):

Phone (alternate):

3. Secondary Emergency Contact

Name:

Relationship:

Phone (primary):

Phone (alternate):

4. Physician Information

Physician Name:

Phone:

Practice / Clinic:

Address:

5. Medical Conditions

Please disclose any medical conditions that may affect your ability to participate in physical activity:

6. Allergies

Please list any known allergies (medications, food, latex, etc.):

7. Current Medications

Please list any medications you are currently taking:

8. Additional Medical Information

Do you have a history of heart disease? (Yes / No)

Do you have asthma or breathing difficulties? (Yes / No)

Do you have diabetes? (Yes / No)

Do you have epilepsy or seizure disorder? (Yes / No)

Have you had any recent surgeries? (Yes / No)

Are you currently pregnant? (Yes / No / N/A)

If you answered "Yes" to any of the above, please provide details:

9. Medical Authorization

In the event of an emergency, I authorize the facility staff to contact my emergency contacts and seek emergency medical treatment on my behalf. I understand that I am responsible for all associated medical expenses.

10. Acknowledgment

I certify that the information provided above is accurate and complete. I agree to notify the facility of any changes to my medical condition or emergency contacts.

Member Signature

Date

Printed Name

Phone Number