Request edit access
Consent for Exercise Program
Exercise Objectives: The purpose of an exercise progoram is to develop and maintain cardiorespiratory (aerobic) fitness, muscular strength and endurance, body composition, and flexibility. These recommendations follow industry standards and should be condudcted under the supervision of a trainer with a minimum of a national certification.

Procedures: A structured exercise program based on individual needs (obtained fitness assessment information), interests, and/or physician's recommendations will be given to each participant. Exercises may include aerobic activities (treadmill walking/running, cycling, rowing machine exercise, group aerobic activity, swimming, and other such activities), calisthenics and weight lifting to improve muscular strength and endurance, and flexibility exercise to improve joint range of motion. All aerobic programs involve a warm-up, exercise at target heart rate, and cool-down components and follow The American College of Sports Medicine's recommendations.

Potential Risks: All exercise programs/testing are designed to gradually increase work load on the cardio-respiratory and musculoskeletal systems in order to effect improvements. The body's reaction to gradually increasing exercise activities cannot be predicted with complete accuracy. Unusual changes during or following an exercise session may occur. These may include muscular or joint injury, abnormal blood pressure, fainting, disorders of heart beat, and/or very rare instance of heart attack or death.

Potential Benefits: Benefits obtained from a structured and regularly employed exercise program might include a more efficient cardiorespiratory system, an improved musculoskeletal system, a decrease in body fat, a decrease in blood fats, an improvement in psychological function, and a decrease in the risk of heart and other diseases.

Supervision: Your trainer is not responsible for injuries and/or damages that occur when the facility/individual(s) are not supervised by your trainer or during non-operational hours.

Confidentiality: All participant exercise program information will be treated as privileged and confidential and will not be revealed to any person (other than your trainer involved in the participant's exercise program) without expressed written consent. Obtained information, however, may be used for statistical or scientific purposes with right to privacy retained.

Injury and Freedom of Consent: I have read the foregoing and I understand the objectives, procedures, potential risks and benefits, supervision issues, and confidentiality involved. Unless otherwise indicated under the "comments" section below, I certify that I am in good health and have no condition that would limit/prohibit my participation in a structured exercise program. I understand that if there any any questions about the procedures or methods used during an exercise session, I should ask my trainer. I realize that injury may result from improper exercise techniques or misuse of exercise facilities or equipment. I agree to be attentive to all instructions given to me and to exercise and use facilities and equipment correctly. I assume responsibility for monitoring my own condition throughout the exercise program and should any unusual symptom(s) occur, I will cease my participation and inform my trainer. I shall also notify my trainer of any changes in my medical status. I consent to the administration of any immediate resuscitation measures deemed advisable by my trainer or other qualified personnel.
Questions/Comments
Your answer
I have read and understand the above information and voluntarily consent to participate in a structured exercise program. I realize that I am free to terminate the exercise program at any time.
Full Name *
Your answer
Date *
MM
/
DD
/
YYYY
Electronic Signature *
Your answer
Witness (Trainer or Coach will sign off)
Your answer
Date
MM
/
DD
/
YYYY
Thank you for using Premier Performance, Inc. Fitness Forms
Due to copyright, you are not allowed to modify these forms in any way without the expressed written permission of Premier Performance, Inc. You are also not allowed, by law, to sell these forms or modifications thereof.

These forms have important legal consequences. An attorney should be consulted on all important matters including the preparation of legal forms or when you question the suitability of the form for your intended purposes. The American Council of Exercise (ACE) and Premier Performance, Inc will not accept liability for any financial loss or damage in connection with the use of these forms. If you have further questions concerning preparation of these forms, please consult an attorney.

It is the responsibility of the trainer/fitness professional/etc. using these forms to use them appropriately. By using these forms, the purchaser/user of these forms agrees that he/she shall defend, indemnify and hold Premier Performance, Inc and ACE harmless against any claims, liabilities, judgements, losses, costs and expenses, including reasonable attorney fees from claims by the purchaser/user or from third parties arising from the publication, distribution or sale of these forms. Premier Performance, Inc and ACE will not be responsible for any injury, illness, etc. that may occur by those not qualified as fitness professionals as determined by a national organization such as ACE or ACSM, or by those who act in negligence. All procedures should follow the guidelines/standards as stated by ACSM or ACE in providing safe exercise recommendations.
Premier Performance, Inc.
1457 Cambridge Common
Decatur, Georgia 30033
800-689-6273
pperform@bellsouth.net
American Council of Exercise
5820 Oberlin Drive, Suite 102
San Diego, CA 92121-3787
800-825-3636
www.acefitness.org
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy