Participation Authorization form

2010 PARTICIPATION AUTHORIZATION

Name ______________________________________
Birth date (Month & Day) ___________________

Address_______________________________________________________________________________

City/State/Zip___________________________________________________________________________

Phone Numbers: Day _____________Evening __________
Email ___________________________

How did you hear about Jazzercise? _________________________________________________________

The Jazzercise fitness program uses dance to challenge the systems of the body, especially the cardiovascular and skeletal system. The following questions are designed to alert you to the factors which may place you at risk from strenuous exercise. They do not include all physical risks, only the primary causes of heart attack or traumatic injury. IF YOU ANSWER “YES” TO ANY OF THE FOLLOWING, YOU MUST CONSULT YOUR PHYSICIAN BEFORE STARTING THIS PROGRAM.
Yes No
___ ___ 1) Are you a male over 45 or a female over 50 and unaccustomed to vigorous exercise?
___ ___ 2) Are you pregnant or have you been pregnant within the past 3 months?
Date delivered _________________ or Due date ___________________

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

___ ___ 3) Heart trouble, a heart murmur or a heart attack?
___ ___ 4) Pain or pressure in your chest, neck, shoulder or arm?
___ ___ 5) Bouts of irregular or uneven heart action?
___ ___ 6) Frequent lightheadedness or spells of dizziness?
___ ___ 7) A family history of premature coronary artery disease?
___ ___ 8) High blood pressure?
___ ___ 9) Extreme breathlessness after mild exertion?
___ ___ 10) A chronic condition needing special care (e.g. insulin dependent diabetes)?
___ ___ 11) Advice from a physician not to exercise?
___ ___ 12) Muscle, bone or joint problems (e.g.arthritis, rheumatism, low back trouble, bad knees, etc.)?
___ ___ 13) Surgery within the past 3 months?

IF YOU ANSWER “YES” TO ANY OF THE FOLLOWING, WE STRONGLY RECOMMEND THAT YOU DISCUSS THIS PROBLEM WITH YOUR PHYSICIAN BEFORE STARTING:

___ ___ 14) A history of lung problems?
___ ___ 15) A cigarette smoking habit?
___ ___ 16) A weight problem (more than 20 pounds overweight)?
___ ___ 17) High blood cholesterol and/or triglycerides?

I have read all the above and do not need to consult my physician. _____________ (Initials)

My signature below indicates that, having read and understood the material above, I accept the risks associated with this dance fitness program and, further, do hereby release and hold harmless Jazzercise Inc., its officers, directors, employees, and franchisees from any and all liability for injury to my person, whether or not such liability is based on allegations of negligence.

Signature _____________________________Date ______________
Instructor Initials ____________

Signature _____________________________Date_______________
Instructor Initials ____________

Signature _____________________________Date_______________
Instructor Initials ____________