Medical Information Form

LP3 Network requests this form to be completed and submitted online before the Live Activity.

In the event of an emergency, we require the following confidential information:

Name *

Home Phone *

Address *

Date of Birth *

Month

Day

Year

Gender *

Male

Female

Are you currently pregnant or breastfeeding? *

Yes

No

Since you answered yes, you must acknowledge the waiver by clicking the "I Accept" button below:

I am fully aware that the Lab Portion of the training may present a hazard and risk to my person and property if misused. I freely and voluntarily agree to assume the full risk of bodily injury or illness regardless of the severity that I may sustain as a result of my participation. If I am pregnant, have a medical condition or disease or have recently suffered an illness or injury, I should have or did consult my physician before participating. It is my responsibility to exercise the highest standard of safety and caution during the trainings and I hereby release and discharge LP3 Network Inc., their directors, officers and employees, heirs, executors, administrators, agents, assigns and successors, and all other persons, firms, or who might be claimed to be liable, from any and all claims, demands, damages, actions, causes of action or suits of any kind or nature whatsoever, and particularly on account of all injuries, known and unknown, both to my person and property, which may result from my negligence in the handling or use of any such materials. I have fully understood the terms of this release and voluntarily accept.

Acceptance of Waiver *

I Accept

In case of emergency, please contact:

Name *

Relationship *

Emergency Contact Phone Number *

Emergency Contact Address

Primary Treating Physician

Physician Phone Number

Insurance Company

Policy #

Insurance Company Mailing Address

Allergies and special food requirements:

Please list any allergies (including food allergies) or existing medical conditions: *

Please list any allergies to chemicals / perfumes (Lab Session): *

Please list any special food requirements: *

Please provide the following information:

Medical Condition or Disease | Medication | Dosage | Frequency of Dosage *

LP3 NETWORK INC. assumes no additional liability pertaining to the information contained in this form. This document is confidential and shall be held in a secure location at LP3 NETWORK INC and would only be used in the event of an emergency. Note: Certain medical conditions restrict persons from course participation.