Client Release Form
January 18, 2020
Physical activity should not pose any problem or hazard to the majority of people. The following questions are designed to identify the small number of adults for whom physical activity might be inappropriate or those who should seek medical advice prior to initiating a fitness program or other change in their physical activity levels.
Are you over age 55 and/or not accustomed to vigorous exercise?
Have you ever been diagnosed with Type I or Type II Diabetes?
Do you have any reason to suspect that you might now pregnant, or have you been pregnant within the last 3 months?
Have you had any major or minor surgery in the past 3 months?
Have you been hospitalized in the last 2 years?
Are you currently, or have you in the past, ever seen a chiropractor or physical therapist for any condition?
Do you ever experience unexpected shortness of breath, or labored breathing, with or without pain?
Do you currently, or have you ever, experienced unexplained heart palpitations or been diagnosed with a heart murmur or irregular heartbeat?
Have you ever been diagnosed with high blood pressure?
Do you know what your blood pressure normally is?
Do you currently smoke?
Did you ever smoke?
Is there any history of heart disease (prior to age 55) in your immediate family?
Do you know your cholesterol levels? Do you know your cholesterol levels?
Do you receive regular annual physical exams from your primary care physician?
I, , certify that I understand the foregoing questions and my answers are true and complete. I also understand that if this information changes in any way in the future, it is my responsibility to notify my personal trainer, and that I assume the risk for any changes in my medical condition that might affect my ability to exercise.
Before beginning a new fitness program or other significant change in your physical activity levels, you are advised to consult with your physician or primary health care provider. Only a physician or qualified health care provider is able to diagnose and prescribe treatment for specific health conditions.
I acknowledge that I have read the foregoing statements and fully understand the content thereof, and that if I choose not to consult with my physician or primary health care provider, I do so at my own risk.
Regular physical activity is fun and healthy, and increasingly more people are starting to become more active everyday. (Some are also being lazier than ever too.) Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active.
If you are planning to become much more physically active than you are now, start by answering the seven questions in the box below. If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age and you are not used to being very active, check with your doctor.
Common sense is your best guide when you answer these questions. Please read the question carefully and answer each one honestly by checking Yes or No.
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?
Talk with your doctor by phone or in person BEFORE you start becoming much more physically active or BEFORE you have a fitness appraisal. Tell your doctor about the PAR-Q and which questions you answered YES.
You may be able to do any activity you want – as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those which are safe for you. Talk with you doctor about the kinds of activities you wish to participate in and follow his/her advice.
If you answered NO honestly to all PAR-Q questions, you can be reasonably sure that you can:
If you are not feeling well because of a temporary illness such as cold or a fever – wait until you feel better; or if you are or may be pregnant – talk to your doctor before you start becoming more active.
Please note: If your health changes so that you then answer YES to any of the above questions, tell your fitness or health professional. Ask whether you should change you physical activity plan.
EVOLT Training assumes no liability for persons who undertake physical activity, and if in doubt after completing this questionnaire consult your doctor prior to physical activity. I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction.
1. In consideration of being allowed to participate in a fitness assessment and personal fitness program provided by NATE VORONYAK (EVOLT Training) and to use his facilities, equipment and services, in addition to the payment of any fee or charge, I do hereby forever waive, release and discharge EVOLT Training and agents, employees, representatives, executors and all others acting on his behalf from any and all claims or liabilities for injuries or damages to my person and/or property, including those caused by the negligent act or omission of any of those mentioned or others acting on his behalf, arising out of or connected with my participation in any activities, programs or services of Trainer or the use of any equipment provided and/or recommended by Trainer.
2. I have been informed of, understand and am aware that any exercise program, whether or not requiring the use of exercise equipment, is a potentially hazardous activity. I also have been informed of, understand and am aware that any exercise and/or fitness activities involve a risk of injury, including a remote risk of death or serious disability, and that I am voluntarily participating in these activities and using equipment and machinery with full knowledge, understanding and appreciation of the dangers involved. I hereby agree to expressly assume and accept any and all risks of injury regardless of severity or death.
3. I do hereby further declare myself to be over the age of eighteen as of the date of signing this document, physically sound and suffering from no condition, impairment, disease, infirmity or other illness that would prevent my participation in these activities, whether or not the activities require the use of any equipment. I do hereby acknowledge that I have been informed of the need for a physician’s approval for my participation in the fitness program. I acknowledge that either I have had a physical examination and have been given my physician’s permission to participate or I have decided to participate in the exercise activities, programs and use of equipment without the approval of my physician and do hereby assume all responsibility for my participation in said activities, programs and use of equipment.
4. I understand that all information and services provided by (EVOLT is of a general nature and is provided for educational purposes only. None of the information or services provided by Trainer is to be taken as medical or other health advice pertaining to any specific health or medical condition that I may have or have had. The information and services provided by Trainer is not a diagnosis, treatment plan, or recommendation for a particular course of action regarding my health and is not intended to provide specific medical advice.
I, , have volunteered to participate in a fitness program provided to me by (EVOLT) which may include, but may not be limited to, resistance training and aerobic or cardiovascular exercise. In consideration of Trainer’s agreement to instruct and train me, I do here now and forever release and discharge and hereby hold harmless Trainer and his respective agents, heirs, assigns, contractors, and employees from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected with my participation in this or any exercise program including any injuries resulting there from.
THIS WAIVER AND RELEASE OF LIABILITY INCLUDES, WITHOUT LIMITATION, INJURIES WHICH MAY OCCUR AS A RESULT OF (1) EQUIPMENT BELONGING TO TRAINER OR TO MYSELF THAT MAY MALFUNCTION OR BREAK; (2) ANY SLIP, FALL, DROPPING OF EQUIPMENT; (3) AND/OR NEGLIGENT INSTRUCTION OR SUPERVISION.
I, , have been informed of, understand and am aware that any exercise program, whether or not requiring the use of exercise equipment, is a potentially hazardous activity. I also have been informed of, understand and am aware that any exercise and/or fitness activities involve a risk of injury, as well as abnormal changes in blood pressure, fainting, and a remote risk of heart attack, stroke, other serious disability or death, and that I am voluntarily participating in these activities and using equipment and machinery with full knowledge, understanding and appreciation of the dangers involved. I hereby agree to expressly assume and accept any and all risks of injury, regardless of severity, or death.
I have been advised that an examination by a physician should be obtained by anyone prior to commencing a fitness and/or exercise program, or initiating a substantial change in the amount of regular physical activity performed. If I, , have chosen not to obtain a physician’s consent prior to beginning this fitness program with Trainer, I hereby agree that I am doing so solely at my own risk. In any event, I acknowledge and agree that I assume the risks associated with any and all fitness related activities and/or exercises in which I participate. WHICH THEIRIN INCLUDES ANY AND ALL OUTDOOR SESSIONS AND THE ENVIRONMENT IN WHICH THEY ARE USED WITH.
I ACKNOWLEDGE THAT I HAVE THOROUGHLY READ THIS FORM IN ITS ENTIRETY AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. BY SIGNING THIS DOCUMENT, I AM WAIVING ANY RIGHT I OR MY SUCCESSORS MIGHT HAVE TO BRING A LEGAL ACTION OR ASSERT A CLAIM AGAINST TRAINER FOR YOUR NEGLIGENCE OR THAT OF YOUR EMPLOYEES, AGENTS, OR CONTRACTORS.
This form is an important legal document that explains the risks you are assuming by beginning an exercise program. It is critical that you have read and understand this document completely. If you do not understand any part of this document, it is your ultimate responsibility to ask for clarification prior to signing it.
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If you have questions about the contents of this document, you can email the document owner.
Document Name: Client Release Form
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