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Address

Mailing Address:

Mecklenburg County Health Department 249 Billingsley Road Charlotte, NC 28211

Office Location:

Mecklenburg County Health Department 249 Billingsley Road Charlotte, NC 28211

Hours: 8 a.m. - 5 p.m. M - F

Contact

Health Department
704-336-4700

Sample Physical Activity Waiver

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Company Name:___________________________________________________________

Company Address:_________________________________________________________

Employee Participant Name: _________________________________

Dept.:___________________

Date of Birth: _______________ Emergency Contact: ____________________________

During your exercise program, at the above company location, every effort will be made to assure your safety. However, as with any exercise program, there are risks, including increased heart stress and the chance of musculoskeletal injuries. In volunteering to participate in this exercise opportunity, you agree that, to your knowledge, you have no limiting physical conditions or disability that would preclude an exercise program.

A physician’s examination is recommended for all participants with any exercise restrictions, including any heart problems, high blood pressure, chest pain dizziness, relevant surgeries, diabetes, asthma, epilepsy, arthritis, or significant injury to any part of the body. By signing below, you accept full responsibility for your own health and well-being and you acknowledge an understanding that no responsibility is assumed by the company listed above or any other related agency.

The above company and other related agencies are released from any liability now or in the future for conditions that may result from participation in any on-site exercise program including but not limited to: heat attacks, muscle strains, muscle pulls, muscle tears, broken bones, shin splints, heat exhaustion, injuries to knees, injuries to back, injuries to feet, or any other illness or soreness that may occur, including death.

I hereby affirm that I have read and fully understand the above statements.

_____________________________     _________________

Address

Mailing Address:

Mecklenburg County Health Department 249 Billingsley Road Charlotte, NC 28211

Office Location:

Mecklenburg County Health Department 249 Billingsley Road Charlotte, NC 28211

Hours: 8 a.m. - 5 p.m. M - F

Contact

Health Department
704-336-4700