Art Worx Consent Form

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Consent Form for Participating in the

Art Worx Personal Training Program

This is a sample page of the Art Worx Personal Fitness Training Program " Consent Form ". If you wish to mail your Consent Form after your Family Doctor signs it then please mail the completed form to:

Jeffrey L Haggans
314 W Upsal St. 2F
Phila., Pa. 19119

To print a copy for your physician please click here.

Name : _______________________ Tel / Home : ( )______________

Address : _____________________ City : ___________________

State : ______ Zip : __________ Tel / Work : ______________

In Case of Emergency, Contact : __________________ Tel : ( )_____________

General Statement of Program Objectives & Procedures:

I understand that this physical fitness programs includes exercises to build the cardio respiratory system (heart and lungs), the musculoskeletal system (muscle endurance & strength, and flexibility), and to improve body composition (decrease of body fat in individuals needing to lose fat, with an increase in weight of muscle and bone). Exercise may include aerobic activities (treadmill, walking, running, bicycle riding, rowing machine exercise, group aerobic activity, swimming and other aerobic activities), calisthenics exercises, and weight lifting to improve muscular strength and endurance and flexibility exercises to improve joint range of motion.

Description of Potential Risk

I understand that the reaction of the heart, lung, and blood vessel system to exercise cannot always be predicted with accuracy. I know there is a risk of certain abnormal changes occurring during or following exercise which may include abnormalities of blood pressure or heart attacks. Use of the weight lifting equipment, and engaging in heavy body calisthenics may lead to musculoskeletal sprains, pain and injury if adequate warm-up, gradual progression, and safety procedures are not followed. I understand that the seller shall not be liable for any damages arising from personal injuries sustained by buyer while and during the PERSONAL FITNESS TRAINING PROGRAM. Buyer using the exercising equipment during the PERSONAL FITNESS TRAINING PROGRAM does so at his / her own risk. Buyer assumes full responsibility for any injuries or damages which may occur during the training.

I hereby expressly and affirmatively state that I wish to participate in the PERSONAL FITNESS TRAINING PROGRAM provided by Art Worx. I realize that my participation in this activity involves risk of injury, including but not limited to bodily injuries, heart attack, stroke and even death. I also recognize that there are many other risk of injury, including serious disabling injuries, which may arise due to my participation in this activity, and that it is not possible to specifically list each and every injury risk. However, knowing, understanding, and appreciating the material risks and reasonably anticipating that other injuries and even death are a possibility, I hereby expressly assume all delineated risks of injury, all other possible risks of injury, and even death, which could occur by reason of my participation in this fitness program. I hereby fully and forever release and discharge seller, its assigns and agents from all claims, demands, damages, rights of action, present and future therein.

I understand and warrant, release and agree that I am in good physical condition and that I have no disability, impairment or ailment preventing me from engaging or participate (other than those items fully discussed on health history form). I state that I have had a recent physical checkup and have my Personal / Family physician's permission to engage in aerobic and / or anaerobic conditioning.

Description of Potential Benefits

I understand that a program of regular exercise for the heart, lungs, muscles and joints, has many benefits associated with it. These may include a decrease in body fat, improvements in blood fat and blood pressure, improvement in physiological function, and decrease in risk in heart disease. Other benefits may include an increase in muscular strength, muscular endurance, muscle development, overall stamina and self esteem.

I have read the foregoing information and understand it. I have also had an opportunity to ask questions. Any questions that I have have been answered to my complete satisfaction. To confirm this I will sign my name below in the space provided below.

Signature of Participant ___________________________________

Art Worx Representative __________________________________

Date: _____________________________

Jeffrey L Haggans
314 W Upsal St. 2F
Phila., Pa. 19119

To print a copy for your physician please click here.

If you have any questions or comments feel free to e-mail me by clicking the image below.

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