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Intake Form

Gym Health Waiver

To register to our gym please fill out the following medical form

First Name

Email Address

Last Name

Date of Birth

Do you have a doctor’s permit to participate in intense physical activities? *

No

Yes

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

No

Yes

Initials

Today's Date

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

Position

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Enter Your Email

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Location: New York, NY

Tel. 718-312-0340

Email. info(@)systemshostinc(.)com

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