MEDICALLY DIRECTED PROGRAMS

PROGRAM OBJECTIVES:

I understand that my Medically Directed program has been designed specifically to address Diabetes, and And I am electing to participate in this program because I am Diabetic and managing/eliminating it is one of my personal fitness/wellness challenges. I also understand that Diabetes is not something that can be overcome in one program, but must be addressed with gradual changes to achieve long-term goals. I recognize that this program is designed to help me down the long road to achieving my goals, and teach me exercises and behaviors that will safely take me there.

PROGRAM DESCRIPTION:

I understand that my Medically Directed program will involve participation in a number of types of fitness activities. These activities will vary in type, structure, intensity and length, and that at any time I may ask the Trainer to show me a modification to safely reduce the workload while continuing to participate. Activities may be aerobic, muscular strength, muscular endurance, or flexibility oriented in nature, and may include a variety of fitness apparatus, including free weights, selectorized machines, exercise bands, exercise tubing, functional (bodyweight) training, and more.

PROGRAM PREREQUISITES:

I understand that to optimize the efficacy and safety of this program, I will be required to complete a Pre-Program Assessment Interview, a Physician Information Form, and this Informed Consent Form; all under a Trainer’s supervision, and that I will also be required to have my Primary Physician complete a Medical Clearance Form. I understand and acknowledge that I may Enroll in, but may not commence participating in Program Classes until all required forms have been properly completed. I understand that metrics (non-invasive measurements) will be taken at the start of the program (a baseline), and at regular intervals throughout the program, either weekly or monthly. I understand that Resting Blood Pressure, Resting Pulse Ox, Exercise Blood Pressure, and other specific, non-invase measurements will be recorded at each session, and I give Parks & Rec Rx Connect, Inc. permission to view and use my data (without my name) for research purposes. I will inform the Trainer of any medical conditions or potential contraindications to participation, and will obtain a Physician’s Release prior to program commencement.

POTENTIAL PROGRAM RISKS:

I understand that no exercise program is without inherent risks regardless of the care taken by my Trainer, and that my personal safety cannot be guaranteed by the Trainer or the Facility. I realize that when participating in any exercises, particularly those that induce cardiovascular stress, there is a slight chance of serious injury (e.g., heart attack, stroke, or other cardiovascular accidents) or catastrophic incident (e.g., paralysis or death.) I know that engaging in muscular endurance, strength building, and other fitness activities may sometimes results in minor injuries (e.g., bruises, musculoskeletal strains and sprains), less frequent, more serious injuries (e.g., muscle tears, herniated disks, torn rotator cuffs), and rarely, catastrophic injury (e.g., death, paralysis). To maximize mysafety and minimize the risks of any such incidents occuring, I will follow all directions of my Trainer, strive to learn and practice proper form, and inform my Trainer in a timely manner should I desire an exercise modification, or should I feel any unexpected discomfort. “No pain, no gain” has no place here, and I will embrace appropriate safety measures for myself, my fellow participants, and my Trainer.

POTENTIAL PROGRAM BENEFITS:

I understand that a regular exercise program has been shown to produce definite benefits to general health and well-being. I understand that this program has been expertly designed with physician input specifically to address a Diabetes challenge, and will be implemented to produce optimum results leading to long-term benefits. I know that benefits of this program may include loss of weight, reduction of body fat, improvement of blood lipids, lowering of blood pressure, improvement of cardiovascular function, reduction in the risk of heart disease, improved strength and muscular endurance, improved posture, and improved flexibility.

PARTICIPANT RESPONSIBILITIES:

I understand that it is my responsibility to 1) fully disclose any health issues, known contraindications, pre-existing conditions or injuries, and medications that are relevant to participation in a strenuous exercise program; 2) cease exercise and report promptly any unusual feelings (e.g., chest discomfort, nausea, difficulty breathing, apparent injury) during the exercise program; and 3) obtain a Physician Release prior to program commencement.

PARTICIPANT ACKNOWLEDGMENTS:

In agreeing to participate in this Medically Directed Diabetes Program,

Please place a Check (✓) in each box to indicate understanding and agreement.

I have read and understand this entire agreement; I have been able to ask questions regarding any concerns I might have; I have had those questions answered to my satisfaction; and I am signing this agreement freely and with no reservations.