Healthcare Fitness Program

HEALTHCARE FITNESS PROGRAM ENROLLMENT & PARTICIPANT AGREEMENT

Program Enrollment

Program Name:   Start Date:   Program Duration:

Participant Information

Date of Birth:   Gender:

Emergency Contact

Insurance Information (optional)

Medical History & Health Status

Primary Care Physician:   Phone:

Do you have a pacemaker or implanted device? Yes No

Physical Activity Readiness & Program Suitability

The following questions are designed to assess suitability for participation. If you answer Yes to any question, a physician clearance may be required.

1. Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor? Yes No

2. Do you feel chest pain when you perform physical activity? Yes No

3. Have you lost consciousness or suffered from unexplained dizziness in the last 12 months? Yes No

4. Do you have uncontrolled high blood pressure or uncontrolled diabetes? Yes No

5. Are you currently pregnant or have you given birth within the last 6 months? Yes No

Program Goals & Assessment

Consent, Assumption of Risk, Release and HIPAA Authorization

I, the undersigned participant, certify that the health information I have provided is accurate and complete to the best of my knowledge. I acknowledge that participation in the Healthcare Fitness Program involves physical activity and potential risks, including but not limited to musculoskeletal injury, cardiac event, allergic reaction, and exacerbation of pre-existing conditions. I voluntarily assume all risks associated with participation and agree to follow program instructions and safety guidelines.

I release and hold harmless the Program Provider, its employees, contractors, agents, and partnering healthcare professionals from any liability for injury, loss, or damage resulting from my participation, except to the extent caused by the Provider's gross negligence or willful misconduct. This release extends to claims for personal injury, property damage, and wrongful death.

I understand that I may withdraw consent and discontinue participation at any time by notifying Program staff in writing. I acknowledge that if I withdraw, I remain responsible for payment of any services provided prior to withdrawal in accordance with Program policy.

HIPAA Authorization: I authorize the Program Provider to use and disclose my protected health information, limited to medical history, medication lists, fitness assessment data, and emergency contact information, as reasonably necessary to provide program services, coordinate care with health professionals, and in the event of a medical emergency. This authorization includes disclosure to emergency contacts and treating healthcare providers. I understand that I may revoke this authorization at any time by providing written notice, except to the extent that the Provider has already acted in reliance on this authorization.

Authorization Expiration Date:

Physician Clearance: I certify that I have either received physician clearance to participate in this program or attest that I am not required to obtain clearance. If any screening questions were answered Yes, I understand a signed physician clearance may be required prior to participation.

Physician Clearance Obtained: Yes

Participant Acknowledgment

By signing below, I confirm that I have read, understand, and agree to the terms of this Enrollment & Participant Agreement. I affirm that I have had an opportunity to ask questions about the program and associated risks and that my participation is voluntary.

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