BodySTARR LLC Medical Treatment Form

BodySTARR LLC Medical Treatment Form
Full Name*

First NameLast Name
I, the undersigned (Participant) wish to participate in the BodySTARR LLC Group Fitness Programs. (hereinafter the "Program").

In order that I may receive medical treatment in the event of an emergency whereby I may sustain injury or illness during participation in the Program, I authorize any BodySTARR LLC employee to consent to and to request on my behalf medical treatment including x-rays, examination, anesthetic, medical or surgical diagnosis or treatment or hospital care for such an injury or illness during my participation in the Program and I hereby release, discharge, indemnify and agree to hold BodySTARR LLC, Stacey R. Long and their partners, affiliated companies and entities, subsidiaries, agents, representatives, successors, predecessors, assigns, directors, officers, employees, shareholders, heirs, beneficiaries, spouses and attorneys (collectively the The Parties) harmless in the exercise of such authority. I further hereby acknowledge that the The Parties have no obligation to seek any treatment whatsoever on my behalf.

Should the need arise; the following information may be given to any health care provider:
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Number*

Area CodePhone Number
Cellphone number*

Area CodePhone Number
Emergency Contacts
Full Name*

First NameMiddle NameLast Name
Day Telephone Number*

Area CodePhone Number
Evening Telephone Number*

Area CodePhone Number
Please list any medical conditions of the above Participant (asthma, diabetes, epilepsy, etc*
Please list any allergies or allergic reactions to medications of the above Participant: *
Please list any medications the above Participant is taking:*
Date of the Participant’s most recent tetanus shot:*

MonthDayYear
Other pertinent medical information:
Physician Information
Physician Name*

PrefixFirst NameLast Name
Physician Telephone Number*

Area CodePhone Number
Medical Insurance
Medical Insurance Company
Policy Number
I have read and understood the above Authorization for Medical Treatment.
Should be Empty:

BodySTARR LLC Medical Treatment Form

Emergency Contacts

Physician Information

Medical Insurance

I have read and understood the above Authorization for Medical Treatment.