top of page
Log In
Form Intention Studios
Wuji Xiao Yao Kung Fu Academy
Texada Island BC
Menu
Close
HOME
Intake Forms
Waiver
Client Intake Form
Health Declaration
Photography Release
Blog
Health declaration
Please fill out the following form.
First name
Last name
Email
*
Date of birth
Year
Month
Month
Day
Have you been hospitalized in the last 12 months?
No
Yes
Are you suffering from a medical condition, illness or injury?
No
Yes
If you answered yes to any of the questions above, please supply additional information.
Initials
*
I declare that the info I’ve provided is accurate and complete.
*
Submit
Back To Top
bottom of page
