1. With less than 24 hours notice, you will be charged for your
2. It is your responsibility to contact your personal trainer directly
to cancel the appointment and reschedule.
**Please Note: All personalized services packages and gift certificates
purchased must be completed within one year of purchase date.
I understand that there are potential risks to physical activity,
evaluation and testing. I will be working around exercise machines,
exercise accessories (e.g. tubing), testing instruments and involved
in testing protocols (e.g. step test) and could be exposed to some
accidents. I will be participating in exercise activities such as
running and weight training and could be exposed to an injury. This
could include straining or even tearing muscles, tendons, ligaments,
or heart strain even though care will be taken by myself and others
to avoid such injury. I will inform the instructor(s) if there are
any problems during these tests or activities. (These are the usual
risks that are involved with exercise testing and activity.) At
any time I may withdraw my consent and terminate my participation
in the activities described above. I hereby release and hold harmless
the agents, officers and employees of the Vancouver YWCA and affiliated
companies, from any liability with respect to me or my property
arising out of or connected with my partaking of any programs and
courses offered by the Vancouver YWCA. I agree that a Photostat
or Faxed copy of this consent and authorization form is accepted
as the real document.
1) Has your doctor ever said that you
have a heart condition and that you should only do physical
activity recommended by a doctor?
2) Do you feel pain in your chest when you do physical activity?
3) In the past month, have you had chest pain when you were not doing physical activity?
4) Do you lose your balance because of dizziness or do you ever lose consciousness?
5) Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
6) Do you have a bone or joint problem that could be made worse by a change in your physical activity?
a) What type do you have (eg., osteoporosis, arthritis)?
b) Where is it located?
7) Do you have diabetes and/or thyroid problems?
8) Do you have any allergies? What are they?
9) Do you suffer from asthma and/or exercise induced asthma?
10) In your family is there any history of heart problems, arthritis, osteoporosis, diabetes,
asthma or orthopaedic problems? If yes, what are they?
11) Do you have any eye or ear problems? Please describe.
12) Are you on any medication? If yes, please describe
13) Have you ever had any injuries? If yes, what are they?
14) Have you ever had surgery? Please describe, and indicate date
15) Do you smoke?
16) Are you used to doing vigorous exercise (e.g. 20 minutes) 2-3 times per week?
17) Is there a good physical reason, not already mentioned here, why you should not follow an activity program even if you wanted to? If so, please describe.
We advise you that if you are currently taking medication, have
any physical ailment or you are otherwise not in physical condition
suitable for activity, it could be injurious to you. You should
seek medical advice regarding these matters before participating
in these programs. THIS DOCUMENT IS A RELEASE OF CLAIMS AND BY SIGNING
1. Acknowledge that when performing exercise routines or engaging
in similarly strenuous activity, you may suffer injury.
2. Represent to the YWCA that you are in good health and physical
condition and are not disabled, taking medication or suffering from
a condition that would prevent you from engaging in such activities
or make it potentially dangerous or harmful for you to engage in
3. ASSUME THE RISK OF AND HOLD THE YWCA HARMLESS FROM ANY LIABILITY
FOR ANY PHYSICAL OR OTHER INJURY OR HARM SUFFERED BY YOU DURING
OR AS A CONSEQUENCE OF PARTICIPATING IN SUCH PROGRAMS OR PERFORMING
SUCH EXERCISE ROUTINES OR ENGAGING IN SUCH OTHER STRENUOUS PHYSICAL
ACTIVITY, AND AGREE THAT THE YWCA SHALL NOT HAVE ANY LIABILITY OR
RESPONSIBILITY FOR ANY SUCH INJURY OR HARM.
I HAVE CAREFULLY READ, UNDERSTAND, AND AS AN INDUCEMENT TO THE YWCA
TO ALLOW ME TO PARTICIPATE IN THE PROGRAMS, AGREE TO THE FOREGOING.
I have read and understood the above informed consent and release of liability.