Excersise Programs

  

Health Information and Hold Harmless Agreement

Queensbury Parks & Rec

Queensbury Department of Parks & Recreation
742 Bay Road, Queensbury, NY 12804
(518) 761-8216 ~ fax (518) 798-3194


Should be completed and updated annually by anyone participating in the department's exercise programs (Stretch & Tone, Aqua, etc.)

*Required
*Name:
*Gender:

Age:
*Home Phone:

*Emergency Phone:
*What is the present state of your general health?:

Physician's Name:
Physician's Phone:

Person to contact in an emergency:
Phone:

Please list all medications that you presently take:
Are you now or have you been pregnant within the past three months?:

Does your physician know that you are participating in an exercise program:

DO YOU NOW OR HAVE YOU HAD WITHIN THE PAST YEAR:

1. History of heart problems?:
2. High blood pressure?:

3. Difficulty with physical exercise?:
4. A chronic illness?:

5. Advice from a physician not to exercise?:
6. Disorder that is aggravated by exercise?:

7. Recent surgery (within past 3 months)?:
8. History of lung problems?:

9. History of diabetes?:
10. Smoking habit?:

11. High Blood Cholesterol?:

I have carefully reviewed the health information above and attest to its accuracy. I also understand that I may be asked by the instructor or the Parks and Recreation Department to provide a physician's note before participating!

The Undersigned hereby agrees to indemnify, save harmless, and waves liability of the Town of Queensbury, the Town Board, the Parks and Recreation Department, employees and volunteers thereof, for any responsibility should an accident or injury occur to the undersigned participant as a result of participation in any program sponsored by the Queensbury Parks and Recreation Department or while using recreation program facilities.

*Signature of Participant:
*Email:

*Date:

* Information provided by the American Council on Exercise * revised: 5/08

*Passcode:
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