theCENTER @ Columbus Avenue Baptist Church

Waiver with Brief Medical History

Name and Birthdate:

First Name:
Last Name:
Birth Date:

Contact Information:

Mailing Address:
Apt Number:
City:
State:
Zip:
Primary Phone Number:
Email Address:
Confirm Email Address:

Emergency Contact:

Name of Emergency Contact:
Emergency Contact Phone Number:

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?

MARK ONLY ONE

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.

Release of Liability

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.

Please initial:

Risk

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.

Please initial:

Testing and Screening

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.

Please initial:

SIGN BELOW:

Name:
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.