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SBDCRC Holistic Nutritional Coaching & Yoga Therapy Profile

Welcome to Sharron Baucom Dale City Recreation Center! We're excited you have chosen us to join you on your path to a healthier lifestyle.
MEMBER INFORMATION:
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7. Preferred Contact Method
9. Availability Day: Please check all that apply *This question is required.
10. Availability Time

Physical Activity Readiness

11. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?  *This question is required.
12.

Do you feel pain in your chest when you do physical activity? 

*This question is required.
13.

In the past month, have you had chest pain when you were not doing physical activity? 
14.

Do you lose your balance because of dizziness or do you ever lose consciousness? 
15.

Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity? 
16. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
17. Do you know of any other reason why you should not do physical activity?
18. Females: Are you Pregnant?
If you answered YES to one of more questions, you may be required to obtain a medical clearance before beginning an exercise program.

Informed Consent

The undersigned hereby gives informed consent to engage in a series of procedures relative to completing a written medical/health history, taking a battery of exercise tests, and participating in a variety of physical activities. The purpose of the testing is to determine physical fitness, cardiovascular function, and health status. All exercise testing and physical activity sessions will be supervised and monitored by trained fitness staff. These activities include cardiovascular conditioning, strength training, endurance training, flexibility, and/or functional/stability training performed in a fitness-related setting which may include use of exercise equipment.

There exists the possibility that certain detrimental physiological changes may occur during exercise and exercise testing. These changes could include heat related illness, abnormal heartbeats, abnormal blood pressure, breathing difficulties, stroke, heart attack, strains, sprains, fractures and other changes. If abnormal changes were to occur, the staff has been trained to recognize symptoms and take appropriate action, including administering CPR, first aid, and AED. I authorize Prince William County Department of Parks, Recreation & Tourism (PWC DPRT) staff to seek emergency medical attention if needed at any point during an activity. I agree to seek medical attention at any point if PWC DPRT staff discontinues an activity due to any health concerns from participating in that activity.

By clicking "submit" below, I am acknowledging that I have read this form and understand that there are risks associated with any physical activity and the use of equipment, which may result in illness, injury or even death. I recognize it is my responsibility to provide accurate and complete health/medical history information and to seek medical guidance from my physician prior to participating. Furthermore, it is my responsibility to monitor my individual physical performance during any activity. I voluntarily assume the risk of bodily or personal injury to me that results from this activity. I agree to indemnify and hold harmless the PWC DPRT, its employees and agents for any losses and/or injuries to me resulting from my wrongful acts or omissions and from my participation in this activity.
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