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@shenoafox

New REFLECTION & INTENTION 2023 Mindset Workbook is Now Available

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Wild Fox Way Health Waiver

To register to the Wild Fox Way Studio, please fill out the following medical form

First Name

Email Address

Emergency Contact

Last Name

Date of Birth

What would you like to achieve from group sessions?

Have you ever been told you have a heart condition?

No

Yes

Have you lost your consciousness in the last past 12 months?

No

Yes

Have you ever had a stroke?

No

Yes

Do you have any unexplained pains in your chest at rest or during exercise?

No

Yes

Do you suffer from spells of dizziness?

No

Yes

Do you suffer from asthma?

No

Yes

Do you suffer from any medical conditions that may be made worse form physical activity?

No

Yes

Are you pregnant of have you given birth in the past 3 months?

No

Yes

Initials

Today's Date

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

Thanks for submitting!

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