HealthSteps Informed Consent

In consideration of being accepted into this program, I do, on behalf of myself and heirs or executor release and discharge St. Mary's Health System and the HealthSteps staff and all its agents from any claims or demands which I may have now or at any time in the future resulting from any illnesses or injurious occurrences as a result of participation in the HealthSteps program.

I understand that the tests included in HealthSteps may be one or more of the following:
1) Cardiovascular Fitness Testing
2) Muscle Strength & Endurance
3) Flexibility
4) Body Composition Analysis
5) Blood Pressures.

I also understand that every effort is made to promote my well being, and referrals by my physician may need to take place. I am aware that a Medical History form may be sent to my physician upon the decision of the HealthSteps Staff. I understand that the Physician will return the form directly to the HealthSteps office when completed. I also understand that if my physician limits my

exercise routine, my program will be prescribed accordingly and certain testing may have to take place before I continue with the HealthSteps Program.

In signing this consent form I state that I have read and understood the description of the program. Any questions which occur to me have been answered to my satisfaction. I understand that every effort will be made to ensure my health and safety. I enter into the program willingly and may withdraw at any time. There are no refunds given. I certify that I am in good physical health and have no limitations other than those I listed which may predispose me to risk during this program.

I understand that information obtained from the laboratory evaluations, fitness tests and exercise sessions of the HealthSteps program will be treated as privileged and confidential and will not be released without my express written consent. I understand that this information may be used, however, for statistical and/or scientific purposes without infringing on my right to privacy. I approve of periodic forwarding to my physician of data obtained from my evaluations. I agree to look to my physician for medical care. If I experience ANY unusual symptoms during exercise, I will alert the instructor to the nature of the problem IMMEDIATELY.

I release the right to all photographs taken during classes and/or events of the Health Steps program to St. Mary's Health System for current and future publicity purposes.

*Signature of Applicant *Date

Typing your name on this line will act as your electronic signature.

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