Clearance for Safe Exercise Participation

I. Health History

Even though participation in exercise is relatively safe for most apparently healthy
individuals, the reaction of the cardiovascular system to increased levels of physical
activity cannot always be totally predicted. Consequently, there is a small but real risk of
certain changes occurring during exercise participation. These changes include abnormal
blood pressure, irregular heart rhythm, fainting, and in rare instances a heart attack or
cardiac arrest. This questionnaire will enable you to determine your suitability for safely
beginning an exercise routine.

Have you ever had or do you now have any of the following conditions?

Y/N
1. ___ Cardiovascular disease (any type of heart or blood vessel disease, including strokes)
2. ___ Elevated blood lipids (cholesterol and triglycerides)
3. ___ Chest pain at rest or during exertion
4. ___ Shortness of breath or other respiratory problems
5. ___ Uneven, irregular, or skipped heartbeats (including a racing or fluttering heart)
6. ___ Elevated blood pressure
7. ___ Often fell faint or have spells of severe dizziness
8. ___ Diabetes
9. ___ Any joint, bone, or muscle problems (e.g., arthritis, low-back pain, rheumatism)
10. ___ An eating disorder (anorexia nervosa, bulimia, binge-eating)
11. ___ Any other concern regarding your ability to participate safely in an exercise program? If so
discuss them with your instructor.

Do any of the following two conditions apply?

1. ___ Do you smoke cigarettes?

2. ___ Men - Are you age 40 or older?
3. ___ Women - Are you age 50 or older?

II. Medical Conditions

Exercise may not be recommended under some of the conditions listed above; others may simply
indicate special consideration. If you do not feel that it is safe for you to proceed with an exercise
program talk with your instructor prior to starting your basic physical education class. Explain to
your instructor any concerns or limitation(s) that you may have regarding your safe participation in
a comprehensive exercise program to improve cardio respiratory endurance, muscular strength and
endurance and muscular flexibility. You also should promptly report to your instructor any
exercise related abnormalities you experience during the course of the semester.
 Waiver for Safe Exercise Participation

I have carefully read the Clearance for Safe Exercise Participation form and I have
informed the instructor of the following:

____ I do not have a medical condition(s) and wish to participate in the Exercise Program.

____ I do have a medical condition(s) for which I am under the care of a physician. My
physician has informed me that I am cleared to participate in a physical education class at
this time.

As evidenced by my signature, I certify and I understand that if I become ill while participating in
the Exercise Program, I authorize Georgia Gwinnett College and its designated representatives to
request medical attention and to contact the individual(s)named below. I hereby waive liability
and I assume the risks of participating in the Exercise Program, and agree not to sue Georgia
Gwinnett College or the Board of Regents or its employees and agents, except for instances of
gross negligence.

_______ AS EVIDENCED BY MY SIGNATURE, I CERTIFY THAT I UNDERSTAND I HAVE

WAIVED LIABILITY AND AFFIRM THAT I AM EIGHTEEN (18) YEARS OF AGE OR OLDER.

_______ I AM UNDER THE AGE OF EIGHTEEN (18) YEARS OF AGE. MY PARENT/GUARDIAN

HAS READ THE ABOVE AND THE STUDENT AND PARENTAL SECTIONS HAVE BEEN
COMPLETED BELOW.

________________________ __________________________ ____________

Printed Name Participant’s Signature Date

Print Name:_________________________________ Class:___________________

In the event of an emergency, I authorize the College to contact the following person:
Emergency Contact Information:
Name: ________________________________ Relationship: __________________
Address: _________________________________________________________________
Phone: ________________________________ Alternate Contact (pager/cell):
__________________
(If applicant is under 18 years of age, a parent or guardian must execute, in addition to the foregoing
Release and Waiver of Liability, the following for and on behalf of the minor.)
The undersigned, ____________________ (insert parent or guardian name), the parent and natural guardian
or legal guardian of __________________ (minor’s name) executes the foregoing Release and Waiver of
Liability for and on behalf of the minor named herein. I fully consent to the participation of the minor
named herein in the PROGRAM(s) noted above as part of a program of study at Georgia Gwinnett College.
_________________________ __________________________ _________
Parent/Guardian Printed Name Parent’s/Guardian’s Signature Date
 Physician Clearance Form

Dear Physician,

A patient of yours, ________________________, would like to participate in a Basic Physical

Education class at Georgia Gwinnett College. A description of the nature of the class is attached.
Your patient has been referred to you because he/she indicated that an existing medical condition
requires consultation with a physician prior to participation in our class.

____ Individual is cleared to participate in a supervised exercise program.

____ Individual is not cleared at this time to participate in an exercise program

____ Individual should not be allowed to participate in an exercise program

Signature: _________________________________ Date: __________________

Name: _________________________________ Phone: ___________________

Address: _________________________________

_________________________________