Download Informed Consent - Lee County School District

Print Name: ____________________________________________
SDLC Employee Wellness Group Exercise Class Informed Consent
Please fax (335-1506) or pony the completed form to the following address prior to attending your first class: Lee County Public
Education Center • Employee Wellness • Attn: Heather V. Parker
1.
PURPOSE AND EXPLANATION OF CLASS The purpose of the group fitness class is to improve aerobic capacity and/or
muscular strength and endurance. Classes will begin with an appropriate warm-up and end with an appropriate cool-down.
Classes are taught by nationally certified aerobic instructors. I have completed the Physical Activity Readiness Questionnaire
(PAR-Q) and contacted my physician for clearance to exercise if recommended by the PAR-Q.
2.
ATTENDANT RISKS AND DISCOMFORTS There are inherent risks associated with strength training, aerobic conditioning and
other forms of physical activity. Strength training may result in acute muscle and/or joint pain, pulled muscles, brief changes in
blood pressure, light headedness, dizziness, delayed onset of muscle soreness, and chronic conditions such as tendonitis and
other discomforts. Strength training should be postponed or modified if joint injury is present or if pain or symptoms persist.
Aerobic conditioning may result in fast or slow irregular heart rhythm, abnormal blood pressure changes, light headedness,
dizziness, fainting, chest pain and other discomforts. Any physical activity may in rare instance lead to heart attack, stroke or
death, but this is unusual, especially in participants free of known coronary heart disease (CHD), free of any signs or symptoms
of CHD, and with few major risk factors of CHD. All class instructors are CPR certified and are trained to watch for any signs and
symptoms associated with poor exercise response.
3.
RESPONSIBILITIES OF THE PARTICIPANT You must complete the Physical Activity Readiness Questionnaire prior to taking
the exercise class. It is also important to stop exercise and disclose any abnormal symptoms you may be experiencing during
class such as joint pain, irregular heart rhythm, tightness or pressure in your chest, shortness of breath, light headedness,
dizziness and the like. It is also important that you adhere to the recommendations of the class instructor especially with regard
to the choice and intensity of exercises you perform. You should not exercise when you are injured, sick or not otherwise feeling
well.
4.
BENEFITS TO BE EXPECTED It is expected that you will see benefits as a result of regular and consistent participation in the
class. Strength training typically results in numerous physical benefits including improved muscular strength, increased muscle
mass, and possibly in an improvement in physical tasks associated with work, recreation and everyday life. Aerobic conditioning
typically results in health benefits including improved body composition, reduced blood pressure and reduced risk of CHD.
Additional positive benefits include changes associated with improved exercise performance including increased aerobic
capacity, heart and lung function and circulation.
5.
INQUIRIES An important part of the informed consent process is providing you the opportunity to inquire about any aspect of the
on-site group exercise class. Please ask the class instructor if you have any questions or concerns about the class.
6.
USE OF MEDICAL RECORDS AND INFORMATION Any personal information gathered in conjunction with this class will be
kept confidential to the extent provided by law. No identifiable information will be released or revealed to any other party without
your written consent. Information that you are asked to provide on the pre and post questionnaires as well as biometric data may
be used in reports; however, your identity will be removed.
7.
FREEDOM OF CONSENT I agree to voluntarily participate in the on-site group exercise class. I understand that I am free to
deny consent if I so desire now or at any point in the program.
Please Read the Following Statements Carefully and Initial
Initials
________
I acknowledge that I have read this form in its entirety or it has been read to me, and I understand my responsibility in
the group exercise class in which I will be engaged. I accept the risks, rules and regulations set forth. Knowing these,
and having had the opportunity to ask questions which have been answered to my satisfaction, I consent to participate
in the group exercise class.
________
If I am accidentally injured during the group exercise class, instructors will be unable to provide treatment. If injured, I
will be responsible for seeking treatment with my own physician. The Emergency Medical System will be contacted in
the event of a medical emergency.
________
Furthermore, I, for myself and my heirs, fully release from liability and waive all legal claims against the School District
of Lee County for injury or damage that I might incur during participation in the group exercise class.
Signature
_________________________________________
Date
_________________________________
Print Name: ____________________________________________
ATTENTION: Read this form before starting an exercise program.
Physical Activity Readiness Questionnaire (A Questionnaire for People Aged 15-69)
Regular physical activity is fun and healthy. Increasing physical activity is safe for most people; however, some
people should check with their physician before they start becoming much more physically active. If you are planning on
becoming much more physically active than you are now, start by answering the seven questions below. If you are between
the ages of 15-69, this questionnaire will indicate whether you should check with your physician before you start. If you are
over 69 years of age and you are not accustomed to being very active, check with your doctor before you begin. Please read
the questions carefully and respond to them honestly.
1.
Has a doctor ever said that you have a heart condition and that you should only do physical activity recommended
by a doctor?
YES NO
2.
Do you feel pain in your chest when you do physical activity?
YES NO
1
In the past month, have you had chest pain when you were not doing physical activity? YES NO
2
Do you lose your balance because of dizziness or do you ever lose consciousness?
YES NO
5.
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
YES NO
6.
Is your doctor currently prescribing drugs for your blood pressure or heart condition?
YES NO
7.
Do you know of any other reason why you should not participate in physical
activity? YES NO
If you answered YES to one or more questions, talk with your doctor before becoming
more physically active. Discuss the types of activities you wish to participate in and the
results of your PAR-Q.
If you answered NO to all questions, you can be reasonably sure that you can begin
becoming more physically active. Begin slowly and build up gradually.
Delay becoming much more active if you are not feeling well due to a temporary illness such as a cold or fever. Postpone
exercise until you feel better. 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 answer YES to any of the above questions,
tell your exercise class leader. Ask whether you should change your physical activity plan.
Informed use of the PAR-Q: The Canadian Society for Exercise Physiology, Health Canada,
and their agents assume no liability for persons who undertake physical activity, and if in
doubt after completing this questionnaire, consult your doctor prior to physical activity.