Fillable Printable Health and Wellness Consent and Release Form
Fillable Printable Health and Wellness Consent and Release Form
Health and Wellness Consent and Release Form
An Agency of the Jewish Federation of Southern NJ
Health & Wellness Consent And Release Form
The Davis Health & Wellness Complex
at the Betty and Milton Katz Jewish Community Center
Must be 15 years of age to use the free weight area and selected cardiovascular equipment.
Print:__________________________________________________________ Date: __________________________________
Signature:_____________________________________________________ Date of Birth: __________________________
If under 15 – Parent/Guardian Signature:______________________________________ Date: ______________________
Will you be using the Health & Fitness Facilities? Yes________ No________
If yes, may we call you to schedule an orientation? Yes________ No________
Phone #________________________________________
IN CASE OF EMERGENCY CONTACT
Name_____________________________________________ Relationship __________________________________________
Phone Number_____________________________________ Cell Phone ____________________________________________
I. In consideration of being allowed to participate in the activities and programs of the JCC and to use it’s facilities,
equipment and machinery in addition to the payment of any fee or charge, I do hereby waive, release, and forever
discharge the JCC and it’s officers, agent, employees or executors, and all others from any and all responsibilities,
or liability from injuries or damages resulting from my participation in any activities or my use of equipment or in
the above mentioned activities. I do hereby release all those mentioned and any others acting upon their behalf
from any responsibility or liability for any injury or damage to myself, including those caused by the negligent act or
omission of any of those mentioned or others acting on their behalf or in any way arising out of, or connected with,
my participation in any activities of the JCC or the use of any equipment at the JCC. (Please initial)_______
II. I understand and am aware that strength, flexibility and aerobic exercise, including the use of equipment, is a potentially
hazardous activity. I also understand that fitness activities involve a risk of injury and even death, and that I am
voluntarily participating in these activities and using equipment and machinery with knowledge of the dangers
involved. I hereby agree to expressly assume and accept all risks of injury or death. (Please initial)_______
III. I do hereby further declare myself to be physically sound and suffering from no condition, impairment, disease, infirmity,
or other illness that would prevent my participation or use of equipment or machinery except as hereinafter stated.
I do hereby acknowledge that I have been informed of the need for a physician’s approval for my participation in an
exercise/fitness activity or in the use of exercise equipment and machinery. I also acknowledge that it has been
recommended that I have a yearly or more frequent physical examination and consultation with my physician as to
physical activity, exercise and use of exercise and training equipment so that I might have his/her recommendation
concerning these fitness activities and equipment usage. I acknowledge that I have either had a physical examination
and been given my physician’s permission to participate, or that I have decided to participate in activity and use of
equipment and machinery without the approval of my physician and do hereby assume all responsibility for my participation
in activities, and utilization of equipment and machinery in my activities. (Please initial)_______
IV. Teens 13 & 14 years old must take the teen orientation before participating in any physical activities in the
Fitness Center. Once completed teens may use the Fitness Center facilities.
OVER
*Every JCC Member must complete this form prior to use of the Health & Fitness Facilities.
Please answer the following questions as accurately and completely as possible. Your answers will be used to
determine your physical readiness for exercise. All information will be kept strictly confidential
Circle the appropriate response.
1. Has your doctor ever told you that you have a heart condition?
YES NO
If yes, please explain__________________________________________________________________________________
2. Has your doctor ever told you that you have high blood pressure?
YES NO
If yes, please explain__________________________________________________________________________________
3. Has your doctor ever told you that you have elevated cholesterol?
YES NO
If yes, what is your cholesterol level __________________________________________________________________
4. Have you ever had any chest pains?
YES NO
If yes, please explain __________________________________________________________________________________
5. Do you have a family history of heart disease?
YES NO
If yes, please explain __________________________________________________________________________________
6. Have you ever experienced dizziness or fainting?
YES NO
If yes, please explain__________________________________________________________________________________
7. Has your doctor ever told you that you have diabetes mellitus?
YES NO
8. Are you presently taking any prescription medications?
YES NO
If yes, please indicate medication and the condition for which it has been prescribed.
______________________________________________________________________________________________________
9. Do you have any bone or joint problems?
YES NO
If yes, please explain __________________________________________________________________________________
10. Do you smoke?
YES NO
11. If female, are you over 50? If male, are you over 40?
YES NO
12. Is your current lifestyle sedentary?
YES NO
13. Has your doctor ever told you that there is a physical reason for you NOT to exercise?
YES NO
If yes, please explain__________________________________________________________________________________
