ACT 2  Program
FITNESS CLASS CLEARANCE FORM

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Student Information

Exercise Habits
Emergency Contact
WARNING
PLEASE READ: While exercise testing and/or exercise participation is relatively safe for most apparently healthy individuals, the reaction of the cardiovascular system to increased levels of physical activity cannot always be totally predicted. Consequently, there is a small but real risk of certain changes occurring during exercise testing and/or participation. Some of these changes may include but are not limited to abnormal blood pressure, irregular heart rhythm, fainting, in rare instances heart attack or cardiac arrest, as well as certain orthopedic conditions including sprains, strains, fractures and/or dislocations.

 

Exercise may not be advisable under some of the conditions listed below, while others may simply require special consideration. Consider the following questions honestly. If any of the conditions apply, you should consult your medical provider before you participate in an exercise program. If you are unsure if any of the conditions apply, you should consult your medical provider. You should also promptly report to your instructor any exercise-related abnormalities that you may experience during the course of the quarter.

The following questionnaire is designed to help identify individuals who should seek medical advice concerning the extent and activity most suitable for them. If you have any question about your physical or health limitations, seek medical advice. 
Yes No

If you answered "YES" to one or more questions:

Consult your medical provider before participating in this fitness activity.

ACKNOWLEDGEMENT
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