GRANT ATHLETIC AND FITNESS CENTER
Registration Form

NAME:__________________________________Date:_______________ 

Address:_____________________________________________________ 

Phone: Home:_____________________________Work:_____________________ 

Emergency
Contact:________________________Phone:________________________ 
 

Birth Date:____________________ Blood Pressure:_________________ 

What school district do you live in?  _____________________________

1. Are you taking any medications? Yes No 

If yes, please list medication and reason: 

_____________________________________________________________ 
 

ACKNOWLEDGMENT AND RELEASE

I understand that participation in this exercise program is at my own risk. I assume
full responsibility for any injuries arising out of participation in this exercise program. I agree to release the Grant Public School district, its’ employees, and agents from any and all claims that I may have for any injuries arising out of participation in this program. 

I acknowledge that the above statements about assumption of risk were read by me and that I understand them. I hereby agree to the above terms and conditions. 

Signature:_______________________ Date:________________

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