Informed Consent
SouthCrest Wellness and Sports Medicine Center
Informed Consent Form for Exercise Program
EXPLANATION OF PROGRAM: The exercise program you are enrolling in is designed to improve your physical work capacity (fitness level) and is individualized, based on the results of any/all tests that you have taken in the Wellness Center. During this exercise course, you will be supervised and instructed by trained professionals and/or student instructors, who are under the supervision of the professional staff. At times, only the student instructors will be supervising the exercise class. In order to obtain the benefits of the exercise program, you will need to do the work; in other words, the benefits of exercise are directly related to the amount of physical effort you put forth during your exercise periods. Your exercise classes will consist of aerobics (aerobic dance and/or use of machines such as treadmills, stationary bicycles and stair climbers), strength training (using individualized station equipment/machines and free weights), and anaerobic conditioning (using treadmills, stationary bicycles and stair climbers).
POSSIBLE RISKS: The potential risks associated with exercise include: exhaustion, fatigue, fainting, discomfort, pain, high blood pressure, high heart rate, high respiration rate, and on rare occasions, heart attack, stroke or death. The occurrence/non-occurrence of these events depends largely on the exerciser’s ability to recognize his/her own signs/symptoms and take the appropriate action, for example, reducing the intensity of exercise or sitting down to rest.
POTENTIAL BENEFITS: The potential benefits of regular exercise are well documented and can be summarized to include the following: helps control weight, helps you relax, improves you physical work capacity, reduces the risk of heart disease, helps you look and feel better and helps you live longer. However, the benefits may only be available to those who participate in a regular exercise program of sustained intensity.
ADDITIONAL INFORMATION: The professional staff and student instructors have a responsibility to maintain certain decorum in the Wellness Center. As a client of the Wellness Center, you will be expected to not use vulgar language, to only use the equipment in the manner recommended by the staff and to allow your fellow exercisers their opportunity to use the equipment. The Wellness Center also reserves the right to cancel specific class periods with a minimum of forty-eight hours notice. Wellness Center staff and student instructors reserve the right to demand that any client cease certain behaviors and/or leave the premises. All payments transactions are final. NO REFUNDS, partial or complete, will be issued for any reason, including that of injury, illness or relocation of the member. No transfer of fitness center memberships to semesters originally purchased will be allowed.
ACCESSIBILITY: If you have special needs, please contact John Carey at (918) 461-7878.
PARKING: Parking availability may be limited during events held in the UMAC.
MEMBERSHIP DUES: I/We (Member) hereby authorize the Wellness Center to effect payment for monthly dues and approved member charges for the duration of my/our membership through electronic funds transfer, credit card payment, or direct billing*. I understand that dues are the responsibility of each member and are payable on the first of every month, regardless of facility usage.
This authorization is to remain in full effect until the Wellness Center has received WRITTEN NOTIFICATION from me (either of us) of cancellation/suspension by letter THIRTY DAYS IN ADVANCE OF THE MEMBERS NEXT BILLING DATE.
CONSENT BY SUBJECT OR LEGAL GUARDIAN: I have read the foregoing, I understand it and any questions that may have occurred to me have been answered to my satisfaction. I am in good health and do not have any medical condition that could be aggravated by participation in this program, nor would a physician advise me not to participate in this program for any reason.
*Direct billing for corporate accounts only.
Print Name Clearly: _________________________ Date:____________________
__________________________________ ______________________________
Signature (or Legal Guardian if under 18) Witness Signature
Membership Classification Type of Membership
(Check one): (Check one):
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q Union Student
q Union Faculty/Staff
q SouthCrest Associate
q Union District Patron
q SouthCrest Medical Staff
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q Individual membership
q Family membership
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For Office Use Only
Amount Paid $___________ # of Months Paid ________ Expiration Date ___/____/____
Payment Method:
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q Cash
q Check #________ |
q Credit Card
q VISA/MC
q AMEX |
q Payroll Deduction
q Automatic Withdrawal |
Staff Signature: _____________________________
Comments: ________________________________
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