Physical Activity and Exercise Program Indemnity Form

Physical Activity and Exercise Program Indemnity Form

PARTICIPANT INFORMATION

Membership: Are you a current member of the Harrow Bush Nursing Centre?
If no, would you like to become a member?
Gender

EMERGENCY CONTACT INFORMATION

Participant Physical Activity and Exercise Program Guidelines

- Classes and workshops are open to any medically fit person who is able to participate at their own level of exercise activity.
- If you are in any doubt about your medical fitness or have a medical condition, it is your responsibility to obtain a Doctors medical clearance prior to attending the exercise program.
- New participants are required to make the program instructor aware of any medical conditions, complete the Medical Information and Pre Exercise Screening Section on page 2 and if required, provide a medical clearance certificate.
- Current participants if you have been exercising with no adverse effects, please ensure you make the instructor aware if your health and physical condition change.
- Participants must work within their own capacity/comfort zone at all times and rest if needed.
- Participants are asked to respect fellow class participants and should report any adverse development which could affect their own safety or the safety of others.

MEDICAL INFORMATION

Please complete if you are not a current member.

Do you have current Ambulance Cover?

Pre-Exercise Screening

Please complete if you are a new participant This pre-exercise screening does not provide advice on a particular matter, nor does it substitute for advice from an appropriately qualified medical professional. No warranty of safety should result from its use. The screening system in no way guarantees against injury or death. No responsibility or liability whatsoever can be accepted by the Harrow Bush Nursing Centre (HBNC) or the auspiced body for any loss, damage or injury that may arise from any person acting on any statement or information contained in this tool. AIM: to identify those individuals with a known disease, signs or symptoms of disease, who may be at a higher risk of an adverse event during physical activity/exercise. This stage is self-administered and self-evaluated.

1. Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?
2. Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?
3. Do you ever feel faint or have spells if dizziness during physical activity/exercise that causes you to lose balance?
4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?
5. If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months?
6. Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?
7. Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?
IF YOU ANSWERED ‘YES’ to any of the 7 questions, please seek guidance from your GP or appropriate allied health professional prior to undertaking physical activity/exercise.

IF YOU ANSWERED ‘NO’ to all of the 7 questions, and you have no other concerns about your health, you may proceed to undertake light-moderate intensity physical activity/exercise.

By my agreement below, I acknowledge and confirm that:-
- I have read the Participant Physical Activity and Exercise Program Guidelines above (Page 1) and understand that there is an inherent risk in any physical activity or exercise.
- I agree to abide by the rules set out in the Participant Physical Activity Exercise Program Guidelines above (Page 1).
- I believe to the best of my knowledge, all the information I have supplied within the above pre-exercise screening section is correct.
- I consent to my de-identified information being shared with the Primary Health Network (PHN) for the purposes of improving our services
- I agree to release Harrow Bush Nursing Centre and its instructors from any liability in the event of any injury I may sustain as a result of my participation in class.