Informed Consent Statement

In the event I am required to perform therapeutic exercise, it is understood that the program is designed to develop muscular strength, muscular endurance, cardiovascular-respiratory endurance, and flexibility. I recognize that individuals vary in their response to exercise and specific results cannot always be guaranteed. I also may experience muscle pain and physical fatigue during and after participation in exercise. A cardiovascular incident is also a remote possibility. I further understand and agree that the Sport Medicine Clinic's program is not a substitute in any way for a diagnostic evaluation by my physician and I agree to consult with my physician regarding any risk of which I now am unaware or become aware of while participating in the program. Furthermore, I understand that consultation with my physician is recommended prior to exercise.


Routines will be progressive in nature emphasizing movements to improve flexibility and cardiovascular fitness.


I will report to the exercise coordinator any change in physical condition (pain, soreness, injury), new medicaiton, change of medication, or changes of exercise prescription.


I recognize that development of an exercise program is not an exact science, and despite the best efforts possible, it is possible to suffer accidents and medical emergencies, such as heart attacks, stroke, or other cardiopulmonary incidents.


I have read and understand this form and the program it describes, and I do voluntarily request the right to participate in Sports Medicine Clinic's rehabilitation program. I do hereby discharge, release, and hold harmless the Sports Medicine Clinic and any of its personnel participating in this rehabilitation program, from any and all liability for damage of any kind or character resulting from any injury or condition that I may suffer, or may result from such a rehabilitation program.


THESE FORMS HAVE BEEN EXPLAINED TO ME AND I SIGN THEM VOLUNTARILY.


Participant Signature/Date


Witness Signature/Date


Parent or Guardian Signature/Date