Health & Fitness Liability Waiver/Informed Consent Form


Journey to Health

Waldo County General Hospital

Health & Fitness Liability Waiver/Informed Consent Form

I, ________________________________, have voluntarily enrolled in a fitness program offered through the Journey to Health program of Waldo County General Hospital.  I recognize that the program may involve strenuous physical activity including, but not limited to, muscle strength and endurance training, cardiovascular conditioning and training, and other various fitness activities.

I hereby affirm that I am in good physical condition and do not suffer from any known disability or condition which would prevent or limit my participation in this exercise program.  I have been advised that an examination by a physician should be obtained by anyone prior to commencing a fitness and/or exercise program, or initiating a substantial change in the amount of regular physical activity performed.  If I have chosen not to obtain a physician’s consent prior to beginning this fitness program, I hereby agree that I am doing so solely at my own risk.  I understand that it is my sole responsibility to participate in exercises that are appropriate for the current status of my health.  If I have any questions or concerns about whether or not a particular activity is appropriate to my current health status, I understand it is my responsibility to ask my doctor if this activity is appropriate before I participate in such activity.

I understand that this program is not medically supervised, and exercise activities are led by independent fitness instructors or other program participants who are not employees or agents of Waldo County General Hospital.  I agree not to hold Waldo County General Hospital responsible for the actions or omissions of the independent instructors or other program participants.

I understand that the Waldo County General Hospital may, in its sole discretion and at any time, revoke my enrollment in the Journey to Health program.

I understand that any exercise or fitness activity involves a risk of injury, as well as abnormal changes in blood pressure, fainting, and a remote risk of heart attack, stroke, other serious disability or death.  I am accepting such risks and volunteering to participate with full understanding of the dangers involved.  In consideration of my participation in this program, I , _________________________, hereby waive and release Journey to Health and Waldo County General Hospital and its successors and assigns, from any and all claims, costs, liability and expense for any injury, loss or damage whether known, anticipated or unanticipated arising from my voluntary participation and enrollment.

I ACKNOWLEDGE THAT I HAVE THOROUGHLY READ THIS FORM IN ITS ENTIRETY AND FULLY UNDERSTAND IT.  I UNDERSTAND THAT IT CONTAINS A RELEASE OF LIABILITY.  BY SIGNING THIS DOCUMENT, I AM WAIVING CERTAIN RIGHTS I OR MY SUCCESSORS MIGHT HAVE TO BRING A LEGAL ACTION OR ASSERT A CLAIM AGAINST WALDO COUNTY GENERAL HOSPITAL OR THE JOURNEY TO HEALTH PROGRAM.

_________________________________ (Participant Signature)

__________________________________(Date)

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