Informed Consent

CHILD’S HEALTH FORM

Pertaining to Exercise & Informed Consent
Parent Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Child’s Health History
If you answer NO to all the questions, it is reasonable for you to assume that your child is in a suitable physical condition to start a regular graduated strength and conditioning program.

If you answer YES to one or more of these questions, your child is advised to consult with your doctor prior to participating in this program.
Any injuries, muscle or joint pain, past or present that would affect your child’s ability to exercise?*

YesNo
Any heart disease, shortness of breath, or other chronic or acute conditions that would impact your child’s ability to exercise?*

YesNo
Anything within your child’s health history that needs to be disclosed that would negatively affect his or her health in regard to adding exercise?*

YesNo
Does your child have a bone or joint problem or past injuries that could be made worse by a physical activity program?*

YesNo
2) Informed Consent Document
I, the undersigned do hereby agree & acknowledge:
My consent for my child to perform an exercise program designed by a trained fitness professional where it will be supervised by an appropriately qualified person*

AgreeDisagree
My understanding that exercises for my child will consist of one or more of the following components: mobility, cardiovascular, strength, agility, speed, power, jump training, muscular endurance, stamina, balance, coordination and flexibility.*

AgreeDisagree
I fully understand that there are potential risks for my child in an exercise program i.e. episodes of transient light-headedness or possibly loss of consciousness, and I willfully assume these risks.*

AgreeDisagree
My child’s obligation is to immediately inform the coach of any abnormal symptoms that he or she may experience while exercising.*

AgreeDisagree
I acknowledge that any nutritional advice given to my child is not a medical prescription and should be consulted with my healthcare professional and doctor.*

AgreeDisagree
That I have read, understood, and completed the medical screening questionnaire and obtained medical clearance for my child if necessary.*

AgreeDisagree
Child's Name*

First NameLast Name
Child's Age*
Child's School*
Child's Grade*
Sports participation?
What goals do you have for your child?
Any sports-specific goals?
Signature*

Clear
Please print & sign the consent form below.
Should be Empty:

CHILD’S HEALTH FORM

Child’s Health History

2) Informed Consent Document