Informed Consent
1. Purpose and Explanation - The Med-Fit Assessment involves a series of physical activities. The objective of each activity is to determine your functional capacity, establish an appropriate exercise program, and track your progress towards your personal fitness goals. You are expected to set your own pace to whatever intensity level is comfortable for you. You may stop any activity at any time for any reason. The Sports Medicine Technician that supervises each activity may encourage you to slow-down or insist that you stop, depending on the signs of exertion or discomfort that you exhibit during the activity. The general recommendation is to gradually develop a more active lifestyle that involves at least 150 minutes of moderate physical activity per week. Your participation is voluntary. Our intentions are to encourage and guide you in exercising regularly and to help make it fun.
2. Attendant Risks and Discomforts - There is the possibility of certain physiological changes occurring during your participation in our Med-Fit Assessment. These include: shortness of breath, pounding heart beats, palpitations, dizziness, fatigue, impaired coordination, and in extremely rare instances, heart attack, stroke, or death. Every effort will be made to minimize these risks by thoroughly evaluating your health status and carefully observing your participation.
3. Responsibilities of the Participant - It is important for you to disclose to the Sports Medicine Technician that supervises your participation all the information regarding your health status and any previous experience of heart-related symptoms, such as: shortness of breath, pain, pressure, tightness, and/or heaviness in the chest, neck, jaw, back, and/or arms. Your immediate reporting of these or any other unusual symptoms during your participation is critically important. You are fully responsible for disclosing your: a) past medical history, b) current heart-related medications, and c) any and all symptoms that you experience during your participation.
4. Benefits to Be Expected - Your participation will result in obtaining an accurate assessment of your physical fitness. You will gain from your experience: a) an awareness of your functional capacity, b) the effectiveness of your exercise program, and c) your progress towards your fitness goals. If applicable, you should consult your doctor for integrating more physical activity into your medical treatment in order to better manage any sedentary-related condition. Also, aggregate data will be analyzed and reported for the advancement of exercise science and lifestyle therapies.
5. Inquiries - You, your doctor, or your personal trainer are welcome to ask questions about our Med-Fit Assessment and/or your participation. You are encouraged to get any desired clarifications from your supervising Sports Medicine Technician. For more information, visit our website: www.Med-Fit.org. Document any question you ask, as well as the answer you get.
Question:_________________________________________
Answer:__________________________________________
6. Use of Personal Information - The information that is obtained during your participation will be treated as privileged and confidential. It will not be released or revealed to anyone. Aggregate information will be used for statistical analysis and scientific research purposes while fully protecting your identity and right to privacy. Of course, you are always free to share your experience regarding your Med-Fit Assessment with anyone you choose to do so.
7. Freedom of Consent - Your signature below acknowledges that you hereby consent to voluntarily participate in Med-Fit Assessments. You understand that you are free to stop participating at any time. You understand the nature of the activities, their attendant risks and potential discomforts, and that you had the opportunity to ask questions and get answers to your satisfaction.
Participant:______________________________ Date:__________
Parent/Guardian:__________________________ Date:_________
(Required only if Participant is <18 years old.)
Media Release: I grant to Med-Fit and all co-hosting organizations, and to their representatives, employees, and volunteers the right to take photographs and/or videos of me in connection with my participation in Med-Fit Assessments. I authorize the same, and its assigns and transferees, to copyright, use, and publish such materials, with or without my name, and for any lawful purpose, in print and/or electronically for publicity, illustration, advertising, and Web content.
Initials: Participant:______ Parent/Guardian:_____ Date:_________
2. Attendant Risks and Discomforts - There is the possibility of certain physiological changes occurring during your participation in our Med-Fit Assessment. These include: shortness of breath, pounding heart beats, palpitations, dizziness, fatigue, impaired coordination, and in extremely rare instances, heart attack, stroke, or death. Every effort will be made to minimize these risks by thoroughly evaluating your health status and carefully observing your participation.
3. Responsibilities of the Participant - It is important for you to disclose to the Sports Medicine Technician that supervises your participation all the information regarding your health status and any previous experience of heart-related symptoms, such as: shortness of breath, pain, pressure, tightness, and/or heaviness in the chest, neck, jaw, back, and/or arms. Your immediate reporting of these or any other unusual symptoms during your participation is critically important. You are fully responsible for disclosing your: a) past medical history, b) current heart-related medications, and c) any and all symptoms that you experience during your participation.
4. Benefits to Be Expected - Your participation will result in obtaining an accurate assessment of your physical fitness. You will gain from your experience: a) an awareness of your functional capacity, b) the effectiveness of your exercise program, and c) your progress towards your fitness goals. If applicable, you should consult your doctor for integrating more physical activity into your medical treatment in order to better manage any sedentary-related condition. Also, aggregate data will be analyzed and reported for the advancement of exercise science and lifestyle therapies.
5. Inquiries - You, your doctor, or your personal trainer are welcome to ask questions about our Med-Fit Assessment and/or your participation. You are encouraged to get any desired clarifications from your supervising Sports Medicine Technician. For more information, visit our website: www.Med-Fit.org. Document any question you ask, as well as the answer you get.
Question:_________________________________________
Answer:__________________________________________
6. Use of Personal Information - The information that is obtained during your participation will be treated as privileged and confidential. It will not be released or revealed to anyone. Aggregate information will be used for statistical analysis and scientific research purposes while fully protecting your identity and right to privacy. Of course, you are always free to share your experience regarding your Med-Fit Assessment with anyone you choose to do so.
7. Freedom of Consent - Your signature below acknowledges that you hereby consent to voluntarily participate in Med-Fit Assessments. You understand that you are free to stop participating at any time. You understand the nature of the activities, their attendant risks and potential discomforts, and that you had the opportunity to ask questions and get answers to your satisfaction.
Participant:______________________________ Date:__________
Parent/Guardian:__________________________ Date:_________
(Required only if Participant is <18 years old.)
Media Release: I grant to Med-Fit and all co-hosting organizations, and to their representatives, employees, and volunteers the right to take photographs and/or videos of me in connection with my participation in Med-Fit Assessments. I authorize the same, and its assigns and transferees, to copyright, use, and publish such materials, with or without my name, and for any lawful purpose, in print and/or electronically for publicity, illustration, advertising, and Web content.
Initials: Participant:______ Parent/Guardian:_____ Date:_________