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Ice Bath Registration (Symposium)

Full Name

Date of birth

Email Address

Phone Number

Emergency Contact Name

Emergency Contact Phone

Have you done an Ice-bath before?

Have you done an Ice-bath before?
A
B

Health Condition Check

Cardiovascular Issues (History of heart attach, arrhythmia, heart disease, or uncontrolled High Blood Pressure (Hypertension))

Cardiovascular Issues (History of heart attach, arrhythmia, heart disease, or uncontrolled High Blood Pressure (Hypertension))
A
B

Circulatory/Vascular Issues (Raynaud's Phenomenon/Disease, Peripheral Vascular Disease, Cold Urticaria/Hives, or history of deep vein thrombosis (DVT))

Circulatory/Vascular Issues (Raynaud's Phenomenon/Disease, Peripheral Vascular Disease, Cold Urticaria/Hives, or history of deep vein thrombosis (DVT))
A
B

Neurological Conditions (Epilepsy, Seizure disorders, or certain forms of Neuropathy)

Neurological Conditions (Epilepsy, Seizure disorders, or certain forms of Neuropathy)
A
B

Respiratory Conditions (Severe Asthma or Chronic Obstructive Pulmonary Disease (COPD))

Respiratory Conditions (Severe Asthma or Chronic Obstructive Pulmonary Disease (COPD))
A
B

Are you currently pregnant?

Are you currently pregnant?
A
B

Open Wounds or Active Infections (Do you have any severe open wounds, unhealed surgical incisions, or active skin infections?)

Open Wounds or Active Infections (Do you have any severe open wounds, unhealed surgical incisions, or active skin infections?)
A
B

Medications (Are you taking any medications that affects ehart rate or blood pressure, such as Beta-Blockers?)

Medications (Are you taking any medications that affects ehart rate or blood pressure, such as Beta-Blockers?)
A
B

Do you have any other health condition?

Do you have any other health condition?
A
B

If you answered 'Yes' to any of the above questions, please provide details:

Acknowledgement and Consent

I, the undersigned, confirm that I have read and understood the contraindications listed above. I declare that I do not have any of the listed conditions, or I have obtained prior medical clearance to participate in the ice bath experience.
I, understand that cold water immersion carries inherent risks, including but not limited to, the cold shock response, dizziness, and the potential for hypothermia if protocols are not followed. I agree to enter and exit the bath slowly and to immediately stop the session if I feel unwell.

Participant Signature

Signature

Today's Date