• THE ARC OF SAN DIEGO OUR PLACE WELLNESS CENTER REGISTRATION FORM

    If you have questions, please contact Justin Umpierre (jumpierre@arc-sd.com) at 619-685-1175, ext. 246.
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  • *NOTE: This must be a person who WILL ACCEPT responsibility for you/your participant in case of an emergency where you or your emergency contact cannot be contacted. If parents, care-provider, or other person will be out of town while this person is in program, please attach information about where/when they can be contacted.

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  • DISABILITY AND MEDICAL INFORMATION

     

  • HEALTH INFORMATION
    Please place a “check” in the appropriate box. Please answer the following questions completely.

     

  • If yes, provider/parent/guardian MUST attend Our Place classes with participant. Our Place staff DO NOT provide bathroom support for participants.

  • If yes, provider/parent/guardian MUST attend Our Place classes with participant. Our Place staff DO NOT provide provide 1:1 behavioral support for participants

  • MOBILITY INFORMATION


    Please select the appropriate answer. Please answer the following questions completely. 

     

  • BEHAVIORAL INFORMATION


    To be completed by participant's primary caregiver or direct service professional. Please fill out next section completely and attach existing "Behavior Plan" if applicable. 

     

  • MEDICATION LIST

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  • NUTRITIONAL PREPARATION, CLOTHING GUIDELINES, AND PROGRAM RULES

    Please check each section to acknowledge you have read, undestand and consent.

    • Ensure you are well nourished on the day of training.
    • Where possible, consume a high carbohydrate diet in the 24 hours prior to the training sessions (such as pasta,
      potatoes, fruit, etc.) if this fits in your nutritional plan. If you have questions, please consult with your doctor.
    • You are strongly advised to have eaten some food in the four hours preceding training.
    • Ensure you are fully hydrated, particularly in hot conditions. Drink regularly in the days leading up to training,
      particularly in the 12 hours prior to training.
    • Drink water regularly throughout your workout session. Continue to consume adequate fluids following exercise
      to replace any fluids lost during training. 
    • It is recommended that you wear clean shorts or track pants, a cotton t-shirt or athletic/sports top, socks and nonslip athletic footwear with laces securely fastened.
    • No jeans or open toed shoes (i.e. sandals) can be worn to exercise.
    • Remove all restrictive jewelry, watches, bracelets or hanging earrings that may get caught in the equipment.
    • Bring a bottle of water and a small towel.
    • Be kind and courteous to your fellow workout partners at all times
    • Drink water regularly throughout your workout session.
    • Eat at least 4 hours before exercising.
    • Wear clean workout clothes (no sandals or jeans).
    • Wipe down machines with disinfectant wipes after every use.
    • Do not answer/use cell phones in the facility.
    • Be patient and wait for your turn to use a machine.
    • If you are in pain, stop exercising and notify a staff member.
    • Wash or sanitize your hands before and after you exercise.
    • Shower and apply deodorant prior to exercising.
    • If you need help, ask staff for assistance.
    • Have fun!
  • I, the undersigned person, voluntarily sign this agreement, acknowledging I have read and understand the above information. My signature below also confirms that if I failed to understand anything in this document, I have sought and
    received explanation of its meaning and significance to my complete satisfaction.

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  • AGREEMENT OF RELEASE & WAIVER OF LIABILITY

  • 1. That I am participating in the Our Place Wellness Center during which I will receive information and instruction about exercise and health. I recognize that the Our Place Wellness Center’s classes require physical exertion that
    may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved.


    2. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the Our Place Wellness Center. I represent and warrant that I am physically fit and have no medical condition that would
    prevent my full participation in the Our Place Wellness Center.


    3. In consideration of being permitted to participate in the Our Place Wellness Center, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating
    in the Our Place Wellness Center.


    4. In further consideration of being permitted to participate in the classes offered by the Our Place Wellness Center, I knowingly, voluntarily and expressly waive any claim I may have against the instructor or The Arc of San Diego for injuries or damages that I may sustain as a result of participating in these classes.


    5. I, my heirs, or legal representative of such forever release, waive, discharge and covenant not to sue The Arc of San Diego and its officers, directors, employees, agents, sponsors, in-kind donors or volunteers and any of its Our
    Place Wellness Center’s instructors for any injury or death caused by their negligence or other acts.


    I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above.

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  • OUR PLACE WELLNESS CENTER CLASS REGISTRATION


    Participants are registered for Our Place classes on a first come, first served basis. Our Place staff will take every effort to match each participant with their preferred class choices. However, some participants may not be enrolled in all top 3 class choices. All classes are 50 minutes in length.

    **Please RANK each class in order of preference. 1 = Most Preferred Class; 9 = Least Preferred Class **

  • PUBLICITY RELEASE FORM


    The Arc of San Diego is making a concentrated effort to promote the positive activities and successful work of our staff and consumers. This includes working with the local newspapers, radio,television stations and other media
    publications.

     

    Throughout the year, there will be opportunities for various participants to be interviewed and/or photographed as well as identified by name and program.


    Please fill out the form below to inform us of your wishes regarding publicity

  • I have read and/or fully understand the above "Publicity Release" form. In signing this form, I certify that I am in agreement with its intent and purpose.

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  • **Please note that this consent is updated annually and will be kept on file at The Arc of San Diego. You may revoke consent at any time by notifying The Arc of San Diego staff.

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