PUBLIC SPEED CAMP 2009
Saturday at 10 a.m. Check publicspeedcamp.com
for schedule or call 714 655 4617

Answer the following questions to the best of your knowledge:
What is the present state of your health, as you perceive it? ________________________ ____________________________________________________________________

Have you consulted a doctor prior to attending PSC? __________________
Has your doctor said you have heart trouble? __________________
Do you frequently suffer from pains in your chest? __________________
Do you have high blood pressure? __________________
Are you diabetic? __________________
Do you eat a balanced diet? __________________
Are you pregnant? __________________
Do you have back problems? __________________
Do you have difficulty with physical activity? __________________
Have you had surgery in the last 12 months? __________________
Are you taking any medications or drugs? __________________
Do you have arthritis or any other problem that might be aggravated by intense exercise? __________________
Do you have a hernia or any other condition that may be aggravated by intense exercise? __________________

ALL USE OF PUBLIC SPEED CAMP, EQUIPMENT, OR SERVICES IS STRICTYLY AT YOUR OWN RISK. By signing below, participants warrant that he/she is healthy and medically able to use the training equipment and assume all risk and liabilities resulting from such use. In no event shall Public Speed Camp be responsible for consequential or other damage. This form is intended for informal purposes only. It in no way represents acceptability to participate in any exercise activity. A consultation with your physician should be done before starting any exercise program.

ATHLETE SIGNATURE: ___________________________ DATE: ______________
PARENT SIGNATURE: ____________________________ DATE: ______________