PROGRAM OBJECTIVES:
I understand that my Medically Directed program has been designed specifically to address
Obesity, and I am electing to participate in this program because I consider Obesity to be one of
my personal fitness/wellness challenges. I also understand that Obesity 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, a PAR-Q, and this Informed Consent. 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, Electrical Impedence Body Fat
Measurement, 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 if determined necessary
by the Trainer and/or Facility Fitness Management.
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 an Obesity 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 should my Trainer
or any of the Facility Fitness Management deem it necessary.
PARTICIPANT ACKNOWLEDGMENTS:
In agreeing to participate in this Medically Directed Obesity Program,
- I acknowledge that my participation is completely voluntary.
- I understand the potential physical risks involved in participating in the exercise program and I believe that the potential health & wellness benefits outweigh those risks.
- I give consent to certain physical touching that may be necessary to ensure proper technique and body alignment.
- I understand that the achievement of, or progress towards, my health, fitness or wellness goals cannot be guaranteed.
- I have been able to ask questions regarding any concerns I might have, and have had those questions answered to my satisfaction.
- I have been diagnosed by a physician as obese or undesirably overweight, but attest that otherwise I am in good enough physical condition to participate safely, I have no impairment, injury or contraindication which might prevent my participation in such activities, and have been advised to consult with a physician prior to beginning this program if my Trainer or the Facility Fitness Management felt it necessary.
- I have been advised to cease activity immediately if I experience unusual discomfort and feel the need to stop, and I will follow this advice should the situation arise.
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.
