Permission To Partake in Activity

    This form is to be filled out completely and returned the the activity leader prior to participation in the community engagement activity.


     

     

    I recognize that activities involve some degree of risk and that the activity sponsor cannot guarantee the safety of participants. Knowing of this risk, it is my choice to participate. In the event of an accident requiring emergency care, a reasonable effort will be made to notify the emergency contact if practicable. By signature below, I hereby authorize emergency medical treatment and/or hospitalization deemed necessary by emergency response or medical personnel. Participants engaged in these activities are serving as representatives of their community and are expected to maintain the highest standards of behavior at all times. Medical authorization: I authorize staff and volunteers of the program who are trained in the basics of first aid to give first aid when appropriate. I understand that every effort will be made to contact those listed in the emergency contacts in the event of an emergency requiring medical attention. However, if the emergency contact cannot be reached, I hereby authorize the staff and/or volunteers to transport me via the emergency service (911) to the nearest medical facility and to secure necessary medical treatment. I will not hold the program responsible for accidents or injuries that may occur and I agree to be responsible for any charges incurred in the rendering of medical care and treatment.

    I agree to the statements above.

     

     

    EMERGENCY CONTACT INFORMATION-PLEASE PRINT CLEARLY

     

     

     

    Health History Questionnaire
    Regular physical activity is safe for most people. The American College of Sports Medicine Standards indicates that some individuals should check with their doctors concerning their participation in an exercise program. To help us determine if you should consult with your doctor, read the following questions carefully and answer each one honestly.

    Please Check YES or NO
    YesNo 1. Do you have a heart condition?
    YesNo 2. Have you ever experienced a stroke?
    YesNo 3. Do you have epilepsy?
    YesNo 4. Are you pregnant?
    YesNo 5. Do you have diabetes?
    YesNo 6. Do you have emphysema?
    YesNo 7. Have you had an asthma attack within the last two years or are you taking asthma medications?
    YesNo 8. Do you feel pain in your chest when you engage in physical activity?
    YesNo 9. Do you have chronic bronchitis?
    YesNo 10. In the past month, have you had chest pain when you were not doing physical activity?
    YesNo 11. Do you ever lose consciousness or do you ever lose control of your balance due to chronic dizziness?
    YesNo 12. Are you currently being treated for a muscular-skeletal problem that restricts you from engaging in physical activity?

    YesNo 13. Has a physician ever told you or are you aware that you have high blood pressure?
    YesNo 14. Has anyone in your immediate family (parents/brothers/sisters) had a heart attack, stroke, or cardiovascular disease before age 55?
    YesNo 15. Has a physician ever told you or are you aware that you have a high cholesterol level?
    YesNo 16. Do you currently smoke?
    YesNo 17. Are you a male over 44 years of age?
    YesNo 18. Are you a female over 54 years of age?
    YesNo 19. Are you currently exercising LESS than 1 hour per week? If you answered no, please list your activities in the box below.
              
    YesNo 20. Are you currently taking medication for blood pressure or a heart condition?

    If you answer, “YES” to any one of questions 1-12, or answer, “YES” to 2 or more of questions 13-19, we recommend that you receive medical clearance to your participation in an exercise program.
    I have read, understood, and completed this questionnaire. Any questions that I had were answered to my full satisfaction.