Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Do you suffer or have you suffered from heart disease? *

Yes

No

Do you suffer or have you suffered from high or low blood pressure? *

Yes

No

Do you suffer or have you suffered from diabetes? *

Yes

No

Do you have any allergies / intolerances / dietary requirements we need to be aware of? (including but not limited to stings, foods, animals, plants and medicines) *

Yes

No

Have you ever experienced dizziness, fainting, or shortness of breath during physical activity? *

Yes

No

Has your doctor ever advised you against exercise due to illness/ injury? *

Yes

No

Have you had any major surgery in the last 12 months? *

Yes

No

Are you currently taking any medications or supplements? *

Yes

No

Do you know of any reason why you should not undertake cold water immersion? *

Yes

No

Are you pregnant? *

Yes

No

Have you ever participated in an ice bath or cold water immersion before? *

Yes

No

Please confirm that you can swim at least 25m unaided *

Yes

Declaration *

I hereby agree that I am participating in waterfall walks offered by Caroline Thompson or Beyond Cold Water Therapyy, during which I will receive information and instruction about healthy and safe practice. I confirm that I have thoroughly read and understood the information and conditions presented. I acknowledge the inherent risks associated with physical activities, including cold water therapy, and assert that I am physically fit and have disclosed any medical conditions that may affect my participation in the workshops led by Caroline Thompson and Beyond Cold Water Therapy. I accept full responsibility for my health and well-being during and after these sessions, including any adverse effects that may arise from the practices taught. I hereby release Caroline Thompson and Beyond Cold Water Therapy, along with any affiliated instructors or entities, from any claims, injuries, or damages that I may incur as a result of my participation. I have read the above release waiver of liability and fully understand its contents.

First Name

Last Name

Date

MM

DD

YYYY

I declare that the information I have provided is accurate and complete. I will notify Beyond Cold Water Therapy if anything changes. *