In order for Grossmont College's Adapted Exercise Program to provide you with a personalized and safe program, we request that you complete a Physician's Clearance for
Adapted Exercise Form and a Health Questionnaire prior to participation in one of our classes. Please complete all areas and questions. The Physician's Clearance for
Adapted Exercise Program requires information and a signature from your doctor. This form may be faxed directly from
your Doctor to the fax number listed on the form. The Health Questionnaire may be mailed or given to me, Kathleen Aylward. All information is kept confidential.
If you have any questions or need any assistance, please do not hesitate to contact me: