Consent Form - Saint Joseph Mercy Health System

HEALTH PROVIDER CONSENT TO PARTICIPATESENIOR FITName of Patient: _________________________________________________________Patient Phone Number: __________________________________________________I hereby consent to the participation of the above named individual in the senior exerciseprogram. I am unaware of any medical or surgical condition(s), which the individualpossesses which would be considered a contraindication to exercise.Please note any recommendations or restrictions appropriate for your patient in thisexercise program:________________________________________________________________________________________________________________________________________________All fields requiredPhysician’s name: (printed or typed)__________________________________________Physician’s signature: _____________________________________________________Date: _____________________________ Physician’s phone: _____________________Physician’s address: ______________________________________________________City: ______________________ State: _______________ Zip code: ______________Please mail this completed form to:St. Joseph Mercy Senior Health ServicesSenior Fit5320 Elliot DriveYpsilanti, MI 48197-OR-Fax completed form to:734-712-5499

Participant and Provider Annual Information ReleaseSenior FitPARTICIPANT INFORMATION RELEASEI understand this physical fitness program is a group exercise activity that may includeexercises to build the cardio-respiratory system (heart and lungs) and the musculoskeletalsystem (muscle endurance, strength, and flexibility). Components may include, but arenot limited to, low impact aerobics, strength training, stretching, balance andcoordination exercises.There are potential risks with any exercise program. I hereby certify I know of nomedical problems and accept any risk of illness or injury as a result of my participation inthis exercise program. I understand it is my responsibility to inform the classinstructor(s) of any medical conditions I may have. Furthermore, I agree to wearappropriate exercise clothing and supportive athletic shoes to class. I understand clogs,sling-back shoes, sandals and bare feet are not allowed.I hereby release and hold harmless St. Joseph Mercy Health System, the siteowner/operator of the exercise program, and their agents, employees and independentcontractors from any and all liability, damage, expense, causes of action, suits, claims orjudgments arising from injury, damage or loss to me or my personal property which mayarise from my participation in this exercise program.Name: ____________________________________________________________Address: __________________________________________________________City: ___________________ State: ______________ Zip Code: ______________Phone: (day)______________________ (evening)_________________________Race: (OPTIONAL)__________________ Date of birth: ____________________Emergency Contact Name: ________________________ Relationship: _________Phone: ___________________________ Cell phone: ________________________Participant’s signature: ________________________________________________