Membership HWC Application Form - English /Spanish 2021

Name*

First NameMiddle NameLast Name

Birthdate *

Date

Gender*

MaleFemaleOther

Primary language:*

EnglishSpanishOther

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell phone number*

Home phone number

E-mail address

example@example.com

Preferred mode of contact:*

PhoneEmailPostal mailText

May we contact you by:

EmailText

I would best describe my race as:*

I would best describe my ethnicity as:*

Hispanic/LatinoNon-Hispanic/Latino

Highest level of education:*

Marital status:*

Main source of transportation:*

Do you have health insurance?*

YesNo

Health insurance type:

Do you have a primary health care doctor?*

YesNo

Primary care doctor type:

Have you ever had any of the following health problems? (Check all that apply)*

High blood pressureHigh cholesterolDiabetesNone

In general, would you say your health:*

In the past 12 months, how many visits to the emergency department did you have?*

In the past 7 days, how many days did you engage in physical activity?*

On the days you were active, how many minutes did you engage in physical activity?

Do you have access to fruits and vegetables in your neighborhood?*

YesNo

Would you like to apply for the Supplemental Nutrition Program (SNAP)?*

YesNo

Would you like to be contacted for participation in health research studies?*

YesNo

In a normal day, how many servings of fruit do you eat? (A serving is equal to: 1 medium piece of fruit, 1/2 cup of fruit salad, 1/4 cup of raisins, apricots or dried fruit, or 4 oz. of 100% orange, apple, or grapefruit juice)*

In a normal day, how many servings of vegetables do you eat? (A serving is equal to: 1 carrot or other fresh vegetable, 1 small bowl of green salad, 1 cup leafy vegetables, or 1/2 cup cooked vegetables)*

Tell us about your health goals: (Check all that apply)*

I will participate primarily at the following location:

Juanita J. Craft Recreation Center (4500 Spring Ave Dallas 75210)Anita Martinez Recreation Center (3212 N Winnetka Ave Dallas 75212)Cummings Recreation Center (2976 Cummings St Dallas 75216)Samuell Grand Recreation Center (6200 E Grand Ave Dallas 75201)

Membership Consent and Participation Form

The following information describes the services and activities offered by Baylor Scott & White Health and Wellness Center at Juanita J. Craft Recreation Center (BSW HWC) and your role as a member and participant in them. BSW HWC staff will answer any questions you have about the services and activities it offers, this form, and your participation in these services and activities. Please read this form carefully and do not hesitate to ask any questions you may have.

Purpose
BSW HWC offers comprehensive health and wellness services with an emphasis on access to care, health education, nutrition and physical activity. BSW HWC is a model for population health, community collaboration and innovation; all aimed at meeting the comprehensive health and wellness needs of its members.

Screening
If you become a member of BSW HWC, you will undergo various screenings to help provide a picture of your health and wellness.

Wellness Services
Based upon the results of your screenings, BSW HWC may conduct a further assessment of your individualized needs and may recommend and provide various education and wellness services to you including, but not limited to, chronic condition self-management education, other disease- specific (such as hypertension, heart disease, etc.) education, counseling and management services, nutrition counseling, cooking classes, exercise classes, general fitness guidance, individual fitness training with an exercise specialist, and classes related to emotional coping. Other health and wellness programs and services may also be available to you from time to time at BSW HWC.

Discomforts and Risks
Due to the nature of certain screenings and wellness services, and through no fault of BSW HWC or its staff, you may be at risk of physical and/or emotional injury. The risks associated with a finger stick for blood collection are usually minimal and may include soreness accompanied by inflammation. The risks associated with exercise classes and fitness training may include heart problems and physical injuries to bones and muscles. By voluntarily participating in the services and activities offered by BSW HWC, you recognize and accept all of the risks associated with them, and you release and forever discharge and agree to hold harmless BSW HWC from any and all liability arising from your participation in them.

Additional Medical Treatment
The screenings and wellness services at BSW HWC are not a substitute for an examination by your physician. You are responsible for engaging and following up with your primary care physician or other physician if you have any questions or concerns about your health or about the results of any screenings or wellness services. Further, BSW HWC is not responsible for the costs of any such follow-up care.

Photograph, Video, Record, and Interview
You give your consent to BSW HWC, Baylor Scott & White Health, its affiliates, assigns, contractors and employees and members of its/their medical and allied health staffs (collectively, “BSWH”) to be photographed, videotaped, recorded and interviewed by BSWH representatives, news media representatives, production companies, advertising agencies and any other individual or entity for use by BSWH for the purposes of education, promotion, advertising, publication and distribution, both within and outside BSWH, including at professional meetings, symposiums, poster sessions and other events, in any and all media, including but not limited to newspapers, television, radio, magazines, advertising, BSWH publications or video productions, the Internet, social media websites, and professional medical or healthcare journals. You recognize that the precise manner in which the photograph, video, recording and interview may be used will be determined solely by the aforesaid media and that BSWH has no control over or responsibility for the use of such photograph, video, recording and interview. You acknowledge that this consent shall be effective from the date of signature until revoked and shall include any and all photographs, videos, recordings or interviews obtained during such period of time and any and all uses made of such photographs, videos, recordings or interviews during such period of time. You understand that you may revoke this consent by providing the BSWH Office of Corporate Compliance, 301 N. Washington Ave, Dallas, TX 75246 , a written request stating your intent to revoke the consent.

You acknowledge that this consent is not a commitment by BSWH to use the photograph, video, recording or interview obtained with this consent and that BSWH reserves the right not to use the photograph, video, recording or interview. You hereby relinquish any right, title or interest in such photographs, videos, recordings or interviews, and to any control over their use, and to any proceeds that may arise therefrom. You acknowledge that you will not receive any compensation for such photographs, videos, recordings or interviews. You hereby release and forever discharge and agree to hold harmless BSWH from any and all liability arising from the photograph, video, recording or interview and/or any use by BSWH of the photograph, video, recording or interview. You also acknowledge that BSWH may conduct a background check on you using publicly available records.

Consent and Participation
You are making a decision whether or not to become a member of BSW HWC and participate in the services and activities it offers. You should not sign this form until you understand all the information presented in it and all your questions have been answered to your satisfaction. Your signature below indicates that you have decided to become a member of BSW HWC and participate in the services and activities it offers after having read (or been read) the information provided above and after having had all of your questions answered to your satisfaction.

Name*

First NameLast Name

Signature*

Date*

Date

Membership Application