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Health Declaration

Please fill out the following form
in order to participate in our activity.

Do You Experience Any Of the Following? Select All That Apply.
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Welly Academy - Tanja Akerman

Informed Consent & Liability Release


General Statement of Program Objectives and Procedures:


I understand that this physical fitness program includes exercises to build the cardiorespiratory system(heart and lungs), the musculoskeletal system (muscle endurance and strength, and flexibility), and to improve body composition(decrease of body fat in individuals needing to lose fat, with an increase in weight of muscle and bone).  Exercise may include aerobic activities (treadmill, walking, running, bicycle riding, rowing machine exercises, group aerobic activity, swimming and other aerobic activities), calisthenic exercises, and weight lifting to improve muscular strength and endurance and flexibility exercises to improve joint range of motion.


Description of Potential Risks:


I understand that the reaction of the heart, lung, and blood vessel system to exercise cannot always be predicted with accuracy.  I know there is a risk of certain abnormal changes occurring during or following exercise which may include abnormalities of blood pressure or heart attacks. Use of the weight lifting equipment, and engaging in heavy body calisthenics may lead to musculoskeletal strains, pain and injury if adequate warm-up, gradual progression, and safety procedures are not followed. I understand that the personal trainer (seller) shall not be liable for any damages arising from personal injuries sustained by client (buyer) while and during the personal training program. Client (buyer) using the exercising equipment during the personal training program does so at his/her own risk. Client (buyer) assumes full responsibility for any injuries or damages which may occur during the training.


I hereby fully and forever release and discharge personal trainer (seller), it’s assigns and agents from all claims, demands, damages, rights of action, present and future therein.


I understand and warrant, release and agrees that I am in good physical condition and that I have no disability, impairment or ailment preventing me from engaging in active or passive exercise that will be detrimental to hear, safety, or comfort, or physical condition in I engage or participate ( other than those items fully discussed on health declaration form).


I state that I have had a recent physical checkup and have my personal physician’s permission to engage in aerobic and/or anaerobic conditioning.


Agreement to Participate:

I am enrolling in a program of strenuous physical activity including, but not limited to, walking, hiking, group fitness classes, such a yoga, aquafit, which may include the use of various pieces of fitness equipment offered by Tanja Akerman/ Welly Academy.  I am aware that participating in these types of activities, even when completed properly, can be dangerous. I agree to follow the verbal instructions issued by the fitness professional.  I am aware that potential risks associated with these types of activities include, but are not limited to, death, serious neck and spinal injuries that may result in complete or partial paralysis or brain damage, series injury to virtually all bones, joints, ligaments, muscles, tendons, and other aspects of the musculoskeletal system, and serious injury or impairment to other aspects of my body, general health and wellbeing.


Because of the dangers of participating, I recognize the importance of following the fitness professional’s instruction regarding proper techniques and training, as well as other organization rules.


I am in good health and have provided verification from a licensed physician that I am able to undertake a general fitness-training program. I hereby consent to first aid, emergency medical care, and admission to an accredited hospital or an emergency care centre when necessary for executing such care and for treatment of injuries that I may sustain while participating in a fitness-training program.


I understand that I am responsible for my own medical insurance and will maintain that insurance throughout my entire period of participation with Tanja Akerman/ Welly Academy. I will assume any additional expenses incurred that go beyond my health coverage.  I will notify Tanja Akerman/ Welly Academy of any significant injury that required medical attention(such as emergency care and hospitalization)


Description of Potential Benefits

I understand that a program of regular exercise for the heart, lungs, muscle and joints, has many benefits associated with it. These may include a decrease in body fat, improvement in blood fats and blood pressure, improvement in physiological function, and decrease in heart disease, and many other health benefits.


I have read the foregoing information and understand it. Any questions which may have occurred to me have been answered to my satisfaction. 


E-signature  (Once document has been submitted)

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