Exercise, Falls Prevention, and Wellness Program Registration & Waiver

Exercise, Falls Prevention, and Wellness Program
Community Care Peterborough will protect your privacy. The Personal Information provided by you in this Waiver and Release is collected and used by Community Care Peterborough for the purpose of processing your request to participate in this activity and to provide you with information about our other programs, services and activities. By completing this form, you are consenting to Community Care Peterborough collecting personal health information necessary for the provision of services to you and sharing this information with other providers in accordance with policy CLI-1-22. You have the right to refuse sharing your personal health information with Community Care without being denied service. You may select the option - Prefer not to answer. Please contact us if you do not wish to receive this information or if you wish to receive a copy of our Privacy Policy. Community Care Peterborough - 705-742-7067 or privacy@commcareptbo.org
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Health Information

Please check the health conditions that you are currently experiencing or have experienced in the past year. If you do not wish share info please choose, "Prefer not to answer"
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Exercise, Fall Prevention, and Wellness Program

If you’re new to exercise, returning after a break or are experiencing new health conditions, we recommend that you check with your primary health care provider (e.g. family doctor or nurse practitioner) to ensure that our classes are safe for you. You may direct them to the class descriptions available in the catalogue or to the sample class videos. Information is available on the Community Care Peterborough website: www.commcareptbo.org
In the past year, has your family doctor, nurse practitioner or other health provider said that you should avoid or limit exercise or physical activity?*

YesNoPrefer not to answer
If Yes to above please list the precautions given to you.
In the past year, have you undergone surgery?*

YesNoPrefer not to answer
If Yes to above please list the surgery or surgeries.
I’d like the EFP Coordinator to contact me to discuss my health challenges and which classes*

YesNo
How did you hear about our classes?*
Waiver Release

I have voluntarily enrolled in a fitness program offered by Community Care Peterborough. I recognize that the program may involve moderate 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 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. I agree not to hold Community Care Peterborough responsible for the actions or omissions of the instructors or other program participants. I understand that the instructors and/or Community Care staff may, in its sole discretion and at any time, revoke my enrollment in the Group Exercise 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 Community Care Peterborough 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.

BY TYPING MY NAME AND ENTERING TODAY'S DATE BELOW, I ACKNOWLEDGE THAT I HAVE THOROUGHLY READ THIS FORM IN ITS ENTIRETY AND FULLY UNDERSTANDIT. 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 ACLAIM AGAINST COMMUNITY CARE PETERBOROUGH.
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