VWP Enrollment Check List: Medical Clearance

CELEBRATE HEALTH – Virtual Wellness Program
MEDICAL CLEARANCE & WAIVER FORM
Participant Information
Name: ___________________________
Date of Birth: / _____
Program Start Date: / _____
Contact Email: _____________________
Contact Phone: _____________________

Section A – Physician Clearance (Preferred)
I, Dr. ____________________________, certify that the above-named participant is medically cleared to engage in moderate physical activity, including strength, cardio, and flexibility exercises, with the following modifications/restrictions (if any):

Physician Name & Credentials: ________________________________
Physician Signature: ______________________ Date: / _____
Office Contact Info: ________________________________

Section B – Participant Waiver (If Physician Clearance Not Available)
I, the undersigned participant, acknowledge that I am voluntarily participating in the Corporate Tune Up program. I understand that physical activity may involve risk of injury and that I am responsible for my own health and safety. I release Celebrate Health, its consultants, staff, and partners from any liability resulting from my participation.
Participant Signature: ______________________ Date: / _____

Emergency Contact
Name: _____________________ Relationship: ______________
Phone: ____________________