awimaquatics2

FEARRINGTON SWIM & CROQUET CLUB, INC.

Medical Approval for Exercise Activities

Name: _____________________________________________________________

Post Office Box: _____________________________________________________

Class (check one): Aquasize _______
PEP (Pool Exercise Program) Aerobics ________

Physician’s Name: ____________________________________________________

Physician’s Address: __________________________________________________

______________________________________ is physically capable of participating in
(name)
exercise activities, both inside and outside the pool,without restrictions or limitations.

OR

_______________________________________is physically capable of participating in
(name)
exercise activities with the following restrictions or limitations:

__________________________________________________ __________________
Physician’s Signature Date

PLEASE RETURN BOTH FORMS TO CHUCK GIARDINO AT 647 SPINDLEWOOD DRIVE OR THE SWIM AND CROQUET BOX IN THE GATHERING PLACE KIOSK.
ANY QUESTIONS? CALL CHUCK 542-6900