Have you been diagnosed with a heart condition and should only do physical activity recommended by a doctor?
Do you feel chest pain when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem (for example, back, knee, hip) that could be made worse by a change in your physical activity?
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or for a heart condition?
Do you know of any other reason why you should not do physical activity?
It is advised that you seek further advice from your doctor or a qualified exercise professional BEFORE becoming much more physically active. Tell your doctor about the PAR-Q and which questions you answered YES.
You may be able to do any activity you want-as long as you start slowly and build up gradually. Or you may need to restrict your activities to those which are safer for you. Talk with your doctor about the kind of activities you wish to participate in and follow his/her advice.
Find out which programs are safe and helpful for you.
Yes, I have read and agreed to the disclaimer.
Acknowledgement and Assumption of Risk, Waiver, Release, and Indemnification I acknowledge that while exercise is encouraged to promote both physical and mental health, my attendance at or use 5 Healthy Towns Foundation Centers (Chelsea Wellness Center, Dexter Wellness Center, Stockbridge Wellness Center), including without limitation my participation in any of 5 Healthy Towns Foundation Centers’ programs or activities, 5 Healthy Towns Foundation Centers’ equipment and facilities, and any transportation which may be provided by 5 Healthy Towns Foundation Centers, includes risk of injury and transmission of communicable diseases. I further acknowledge it is impossible to eliminate the risk of injury and the risk of transmission of communicable diseases, which may result from or arise out of my attendance at or the use of 5 Healthy Towns Foundation Centers’ facility or its equipment, activities, or transportation and I knowingly and voluntarily assume all risks of injury and communicable diseases associated with my participation. I acknowledge that I have the responsibility to help reduce the risk of injury and transmission of communicable diseases to myself while in attendance at or using 5 Healthy Towns Foundation Centers’ facility. I agree, on behalf of myself and my heirs, executors, administrators, and assigns, to fully and forever waive, indemnify, hold harmless, release and discharge Power Wellness and 5 Healthy Towns Foundation Centers, their affiliates, their operators, and all of their respective officers, trustees, employees, agents, successors, and assigns, and each of them (collectively, the “Releasees”), from any and all claims, damages, demands, rights of action or causes of action, present or future, known or unknown, anticipated or unanticipated, resulting from or arising out of my attendance at or use of 5 Healthy Towns Foundation Centers’ facility or its equipment, activities or transportation. Further, I hereby agree or waive any and all such claims, damages, demands, rights of action or causes of action. In addition, I hereby agree to release and forever discharge the Releasees from any and all liability for any loss or theft, or damage to personal property. Further, I hereby release and forever discharge and hold harmless Power Wellness and 5 Healthy Towns Foundation Centers and their successors, assigns and third party agents from any and all liability, claims and demands of whatever kind of nature either in law or in equity, which may arise or hereafter arise. I acknowledge that I have carefully read this waiver and release and fully understand that it is a waiver and release of any and all liability. I hereby agree that this assumption of risk and release of liability agreement shall remain in full force and effect until I revoke it by giving written notice to 5 Healthy Towns Foundation Centers, and that my revocation will only apply to events or circumstances occurring after the date of my revocation. I attest that my answers to the physical activity readiness questions are truthful and I acknowledge that I have not provided additional information about my health or participated in a Health Assessment or received any instruction. I also acknowledge that I may choose to participate in individual exercise activity that is not supervised by facility staff. I agree that prior to participating in any exercise activity at the facility, I will affirmatively and personally seek training and/or instruction from facility staff to promote my safe participation in that activity and/or safe operation of any equipment at the facility which I choose to use.
Please provide a Signature.