2025 Studio Beacons Exercise and Physical Consent Form
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Email *
Last Name of Participant *
First Name of Participant *

The participant named above (“Participant”) is enrolled in a program provided by Beacons, Inc., a nonprofit located at 2245 Camino Vida Roble, Suite 100, Carlsbad, CA 92011. The Studio Explorations program is offering a Music and Movement option, which teaches the participants healthy practices to: increase alertness, develop self-regulation techniques, improve stamina and strength, and help to increase sensory/physical coordination.

The Music and Movement option will be led by Thomas Pousti, MD and/or another instructor with a background in the subject area. Staffing ratios will be 3:1 to support participants throughout the activities, which will also be modified based upon any known medical and physical needs/restrictions of participants. Music and Movement will be taught on site or in a non-clinical community-based facility or location that provides sufficient space for participants. Equipment will be provided by the instructor and/or Beacons, Inc.  

To make sure that the Participant wishes to participate and can do so safely, all participants should complete a brief health history questionnaire. Based on the responses, the Participant may need to obtain medical clearance prior to participating in the Music and Movement option to make sure the Participant can safely do the activities and that staff is aware of any restrictions or need for modification of an activity. 

Once completed and signed by you, the Participant should submit this form to Beacons. After review of your answers, you may be required to provide a physician's consent before participating.  

If you have any questions, please feel free to contact me. Thank you,

Andrea Woolley

Director Studio Beacons

Beacons, Inc.

2245 Camino Vida Roble, Suite 100, Carlsbad, CA

Email: Studio@BeaconsNorthCounty.com

Office number: 760-448-6230

Website: www.BeaconsNorthCounty.com


Untitled Title
BEACONS MEDICAL RELEASE TO PARTICIPATE IN BEACONS EXERCISE OPTION

Form should be completed by the party having legal authority over medical decisions involving the Participant. If the Participant is conserved, this form must be completed and initialed by the Conservator. If the Participant is not conserved, the Participant should initial in the appropriate spaces below and sign. Note: For participants who are not conserved, a parent or other designated trusted representative should review this form with the Participant to answer questions and supply if needed. 

This form shall remain in effect for the duration of the calendar year in which this was signed unless rescinded in writing by the participant or the participant’s legal representative.


Purpose and Explanation of Fitness Option:
If you agree, please initial each portion of the purpose and explanation.
If you disagree, please type DISAGREE.
We/I understand that participation in the optional Beacons Music and Movement option may include aerobic activities, walking, running, weight lifting and other activities to build stamina and strength.
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We/I have been informed that during the Participant’s participation in the above described fitness option he/she/they will be asked to complete the physical activities unless symptoms such as fatigue, pain, shortness of breath, chest discomfort or similar occurrences appear.
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We/I understand that it is the Participant’s complete right to decrease or stop exercise and that it is the Participant’s obligation to inform the instructors/personnel of my symptoms, should any problems develop.
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We/I also understand that during the fitness option the physical touching and positioning of the Participant’s body may be necessary to assess the Participant’s muscular and bodily reactions to specific exercises, as well as to ensure that the Participant is using proper technique and body alignment.
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We/I expressly consent to the physical contact for the limited stated reasons above if deemed appropriate and in the group activity in the presence of others. This consent is not intended to provide consent to physical contact outside the group fitness option.
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We/I understand it is the Participant’s complete right to deny consent to any physical contact at any time unless needed for safety or medical reasons.


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We/I understand it is the Participant’s complete right to deny consent to any physical contact at any time unless needed for safety or medical reasons.


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We/I understand that the Beacons exercise activities are not medically supervised and that the Participant’s training program has been developed for healthy people with no prohibitive medical conditions or risks, either physical or psychological. 


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We/I understand it is the Participant’s responsibility to disclose specific injuries or conditions diagnosed by a physician if modifications, accommodations or restrictions are needed.


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We/I will fully disclose any health issues or medications that are relevant to participation in a strenuous exercise program. If the Participant’s physical or mental condition presents limitations to participation, the Participant will obtain a signed Physician Release Form. 


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Choose an answer below:

We/I represent that:

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Required
Please explain any medical reason/s, restriction/s, impairment/s.
Date of Last Annual Physical:
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Physician:
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Potential Risks Statement:
If you agree, please initial each portion of the Potential Risks statement.
If you disagree, please type DISAGREE.

We/I understand and have been informed that there exists the remote possibility during exercise of the Participant having adverse changes including, but not limited to, abnormal blood pressure, fainting, dizziness, disorders of heart rhythm, and in very rare instances heart attack, stroke, or even death. 


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We/I further understand and have been informed that there exists the risk of bodily injury including, but not limited to, injuries to the muscles, ligaments, tendons, and joints of the body, and that every effort will be made to minimize these occurrences by staff supervision and observations during exercise and by the Participant’s own careful control of exercise efforts. 


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 We/I fully understand the risks associated with exercise, including the risk of bodily injury, heart attack, stroke or even death, but knowing these risks, it is the Participant’s desire to participate in the Beacons exercise option.


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Waiver, Release & Indemnification Agreement:
If you agree, please initial each portion of the Waiver, Release, & Indemnification Agreement.
If you disagree, please type DISAGREE.

We/I do forever RELEASE, acquit, discharge, and covenant to hold harmless Beacons, Inc., and its successors, governing body, departments, officers, employees, servants and agents, of and from any and all actions, causes of actions, claims, demands, damages, costs, loss of services, expenses and compensation on account of, or in any way growing out of, directly or indirectly, all known and unknown personal injuries or property damages which we/I may now or hereafter have as the Participant, parent(s) and/or conservator(s) of said Participant, and also all claims or right of action for damages which said Participant has or hereafter may acquire as a result of his/her/their participation in the Beacons exercise option.

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FURTHERMORE, we/I hereby agree to INDEMNIFY and reimburse to Beacons, Inc. or its successors, governing body, departments, officers, employees, servants and agents for any loss or damages or costs, including attorney’s fees, Beacons, Inc. or its representatives may have to pay if any litigation arises from said Participant's intentional, negligent or reckless acts or omissions while participating in said exercise option.

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PHYSICIAN INFORMATION
Please list all physicians and specialists under whom the Participant receives care:
If additional space is needed please use the more information option.
Primary Physician Name *
Primary Physician Phone *
Nature/Scope of Care *
Additional Information
Physician #2 Name
Physician #2 Phone
Nature/Scope of Care
Additional Information
Physician #3 Name
Physician #3 Phone
Nature/Scope of Care
Additional Information
MORE INFORMATION
Please add any addition physician information here.
PARTICIPANT’S CONSENT

Form should be signed by the party having legal authority over medical decisions involving the Participant. If the Participant is conserved, form must be signed below by the Conservator. If the Participant is not conserved, both the Participant and a parent or other designated trusted representative should sign below.

Name of Participant *
Conservator's Name (if applicable)
Participant's Phone Number (or Conservator's if applicable) *
Participant's Signature *
Signature of Conservator (or trusted designee such as a parent if not conserved):
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