Health Screening Form (Page 2 of 2) in pdf

10. Equillibrium

Have you ever lost your balance, or lost consciousness because

of dizziness?

Yes

11. Joint/Extremities

Do you have any history of pain in your joints or extremities,

upper or lower?

Yes

Explain: ________________________________________________________________________________________

Do you have a history of back pain (cervical, thoracic or lumbar) ?

Yes

Explain: ________________________________________________________________________________________

12. Goals

What do you want from your water fitness class?

_______________________________________________________________________________________________

Tri-Community YMCA

Informed Consent for Water Exercise Participation

I desire to engage voluntarily in the YMCA Water Fitness exercise program in order to attempt to improve my physical

fitness. I understand that I am responsible for monitoring my own condition throughout the exercise program and should

any unusual symptoms occur, I will cease my participation and inform the instructor of the symptoms.

Also, in consideration for being allowed to participate in the YMCA Water Fitness exercise program, I agree to assume the

risk of such exercise, and further agree to hold harmless the YMCA and its staff members conducting the exercise

program from any and all claims, suits, losses, or related causes of action for damages, including but not limited to such

claims that may result from my injury or death, accidental or otherwise, during or arising in any way from the water

exercise program.

In signing this consent form, I affirm that I have read this from in its entirety and that I understand the nature of the

water exercise program. I also affirm that my questions regarding the exercise program have been answered to my

satisfaction.

______________________________________________________

__________________________

(Signature of Participant)

(Date)

If you answered yes to one or more of the questions on the screening form, the water exercise

instructors may request that you first consult with your physician as to what sort of exercise program

would be safe and effective for you. We may require written medical clearance from your physician

before allowing participation in a water exercise class. Medical clearances can be mailed, brought in

or faxed directly from the physician’s office to the Aquatics Director at 508-765-5894.

Please return completed health screening form to the Aquatic Director

Health Screening Form Page 2