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Birmingham Canoe Club

The Water is In Our Blood

bccofficial205@gmail.com

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Gym Health Waiver

To register to our gym please fill out the following medical form

First Name

Email Address

Last Name

Date of Birth

Do you have a doctor’s permit to participate in intense physical activities?

No

Yes

Have you lost your consciousness in the last past 12 months?

No

Yes

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

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