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Walton County Parks & Recreation Department Registration / Release Form Activity:_____ SENIOR FITNESS PROGRAM Participant Information (print) Name: / DOB: Age: Sex: (nickname) ) Address: City/County/Zip: Physical / Medical Problem: Shirt Size: AS AM AL AXL AXXL Home Phone Work Phone Cell Phone E-Mail: Emergency Contact: Phone: Comment: Release I acknowledge that I have voluntarily chosen to participate in a program of progressive physical exercise. I also acknowledge that I have been informed of the need to obtain a physician’s examination and approval prior to beginning this exercise program. In signing this document, I acknowledge being informed of the strenuous nature of the program and the potential for unusual, but possible, physiological results including but not limited to abnormal blood pressure, fainting, heart attack or even death. I also understand that I may stop exercising at anytime. By signing this document, I assume all risk for my health and well being and any resultant injury or mishap that may affect my well being or health in any way. I hereby waiver, release, absolve, indemnify, and agree to hold harmless, the Instructor, The Walton County Parks & Recreation Department, their board of directors, employees, and volunteers from any and all liability arising out of any injury suffered by the above said participant during this activity. I understand that the above named parties will not assume responsibility for payment of medical treatment or transportation to or from the place of treatment. First Aid will be administered when necessary with participants consent. I further agree to abide by the policies & procedures set forth by the Walton County Parks & Recreation Department. / Signature Date Print Name Office Use Only Fee Cash:_______Check#:_________Receipt Doctor’s Medical Release: attached / on file ---PAGE BREAK--- WALTON COUNTY PARKS & RECREATION SENIOR FITNESS Low impact cardio & weight bearing exercise program PHYSICIAN’S RELEASE FORM I have Client’s Name I have found the following: above named may participate fully in a progressive physical activity program consisting of cardiovascular, strength and flexibility training without limitation Or: above named may participate in a progressive physical activity program with the following limitations Also: Please list any medication that your patient is currently taking that may affect heat rate or blood pressure response to exercise (elevating or suppressing). If none, write “NONE” The patients ideal target heart rate during cardio exercising should Physician’s Signature Date