theCENTER @ Columbus Avenue Baptist Church
Waiver with Brief Medical History
Physical Activity Readiness Questionnaire (PAR-O):
Has a doctor ever said you have a heart condition and recommended only medically supervised physical activity?
Do you have chest pain when you do physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Has a doctor ever recommended medication for your blood pressure or a heart condition?
Do you have a bone or joint problem that could be aggravated by the proposed physical activity?
Are you pregnant or planning on being pregnant?
Are you diabetic or take medicine to control your blood sugar levels?
Do you take any prescription medications?
Are you physically inactive (you get less than 30 minutes of physical activity 3 days a week)? Do you know of any other reason why you should not do physical activity?
If you marked any of the Questions above, please answer the following questions:
Have you consulted your physician regarding increasing your physical activity and/or performing any fitness assessment?
If you did not mark the above question, will you consult your physician prior to increasing your activity level and/or performing a fitness assessment?
The undersigned guest declares they have completed the above medical questionnaire as required by theCENTER and they declare they are physically able to participate in physical activity.
The undersigned guest acknowledges that theCENTER has advised guest to obtain medical clearance before participating in physical activity in the event that they have answered yes to any of the medical history questions.
The undersigned guest is unsure of their physical health; however, maintains he (she) is physically capable of pursuing physical activity.
In consideration of being allowed to participate in the activities and programs of theCENTER and to use its facilities, equipment and
machinery in addition to the payment of any fee or charge. I hereby waive, release, and forever discharge theCENTER and its officers,
agents, employees, representatives, executors, and all others from any and all responsibility or liability for any injury, death, or damage to myself,
including those caused by negligent act or omission of any of those mentioned or others acting on their behalf or in any way arising out of
or connected with my participation in any activities of theCENTER or the use of any equipment at theCENTER.
I recognize that strength, flexibility, aerobic exercise, and aquatic exercise, including the use of equipment can carry risk to the
musculoskeletal system (i.e. sprains, and strains) and the cardiovascular system (i.e. dizziness, discomfort in breathing, even death), and I am
voluntarily participating in these activities with the knowledge of the dangers involved I hereby agree to expressly assume and accept any
and all risks of injury or death.
I understand and agree that any screening is intended to provide theCENTER with essential information to be used in the developments of an
exercise prescription for myself. I also understand that any screening is not intended to replace any other medical test or the services of my
physician. The undersigned agrees to abide by the rules of theCENTER, including completion of the above medical questionnaire.
The undersigned agrees that use of theCENTER facilities, services and programs shall be undertaken at his (her) sole risk and theCENTER
shall not be liable for injuries, accidents or deaths occurring to guest, arising either directly or indirectly out of utilizing theCENTER’s facilities,
services, and programs. The guest, for himself (herself) and on behalf of his (her) executors, administrators, heirs and assigns, does hereby
expressly release, discharge, waive, relinquish, and covenants not to sue theCENTER at Columbus Avenue Baptist Church, its officers and
agents for all such claims, demands, injuries, damages or cause of action, with respect to use of theCENTER’s facilities, programs and services.
I do hereby further declare myself to be suffering from no disease or disorder that would inhibit, preclude, or complicate my
participation in any future testing or exercise program.
YOU MUST CERTIFY IN ORDER TO PROCEED: I certify that I am the person described above, and that the information presented here is correct to the best of my knowledge.