Fitness Participation Consent Form

FITNESS PARTICIPATION CONSENT FORM

Personal Information

Phone:     Email:

Employment / Position Information

Reporting Manager:     Start Date:     Salary/Rate:

Employment History (Most Recent)

Title:     Dates Employed:

Title:     Dates Employed:

Education

Graduation Date:

References (Professional)

Phone:     Email:     Relationship:

Phone:     Email:     Relationship:

Phone:     Email:     Relationship:

Emergency Contact

Relationship:     Phone:

Medical History & Fitness Screening

Please check any conditions that currently apply to you. If none apply, leave blank.

Heart condition

High blood pressure

Chest pain during activity

Recent surgery or hospitalization

Bone, joint or back problems

Dizziness or fainting

Asthma or breathing problems

Diabetes

Pregnancy

Other (describe below)

Currently taking prescription medication that may affect participation:

I certify that the information above is accurate to the best of my knowledge. I understand that certain medical conditions may require physician clearance prior to participation.

Physician Phone:

Legal Disclosures and Policies

At-Will Employment: Nothing in this fitness participation form alters the at-will employment relationship between the employee and employer. Employment may be terminated at any time by either party with or without cause or notice, except as prohibited by law.

Equal Opportunity: Participation in employer-sponsored fitness activities will be administered without regard to race, color, religion, sex, national origin, age, disability, or any other protected characteristic. Reasonable accommodations will be provided when required by applicable law and when requested in writing.

Acknowledgement of Risk; Release and Indemnity

I acknowledge that participation in physical fitness activities involves risk of personal injury, death, or property loss. I voluntarily assume all risks associated with my participation, including but not limited to slips, falls, equipment failure, and exertion-related injuries, whether foreseen or unforeseen.

In consideration of being permitted to participate, I hereby release, waive, and discharge the employer, its affiliates, officers, directors, employees, contractors, instructors, and agents (collectively the Released Parties) from any and all liability, claims, demands, actions, or causes of action arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, whether caused by the negligence of the Released Parties or otherwise, to the fullest extent permitted by law. I agree to indemnify and hold harmless the Released Parties against any claims, judgments, costs, or expenses arising from my participation.

I further acknowledge that I am responsible for ensuring I follow instructor directions and posted safety procedures. Failure to follow instructions may result in removal from the activity without refund and does not negate this release.

Consent to Treatment and Medical Authorization

In the event of injury or medical emergency, I authorize the Released Parties to obtain emergency medical treatment and to take any other action they deem prudent while attempting to contact my emergency contact and/or physician. I understand I am financially responsible for any medical services rendered.

I authorize the employer and its agents to contact my prior employers and educational institutions for verification as necessary and consent to background checks, drug testing, and verification of the information provided on this form to the extent permitted by law:

Privacy and Photo/Video Release

I acknowledge that photos or video recordings may be taken during activities. I grant permission for the employer to use photographs and video in internal communications, training and promotional materials. I waive any right to compensation for such usage unless prohibited by law. If I do not consent, I will notify the program coordinator in writing.

Participant Certification

I certify that all information provided on this form is true and complete. I understand that falsification or omission of material information may result in disciplinary action, up to and including termination of employment. I have read this document in its entirety, I understand its terms, and I sign it voluntarily.

By signing below I indicate that I have read, understand, and agree to the statements above, including the Release and Indemnity, Consent to Treatment, and Authorizations.

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