Consent for Personal Information
Please review each section carefully and provide signatures as required. This form collects your consent, health statements, and acknowledgment of the cancellation policy for Mind to Muscle services.
Athlete Name
*
First Name
Last Name
Birthdate
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Guardian Name if under 16
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
CONSENT FOR PERSONAL INFORMATION
I_____________________(name above) understand that to provide me with Health Professional Services, Mind to Muscle will collect some personal information about me (e.g., telephone number, address, gender, health history I am aware that Mind to Muscle has a Privacy Policy about the collection, use and disclosure of personal information, steps taken to protect the information and my right to review my personal information.I understand how the Privacy Policy applies to me. - I have been given a chance to ask any questions I have about the Privacy Policies and they have been answered to my satisfaction. I understand and give my consent: - I authorize and direct Mind to Muscle to release to my: Physician, Insurance Company, Rehab Worker, WSIB, Employer, DVA, Lawyers or their representative, or other Health Care Providers - medical reports, x-rays and any other information as requested. - I might receive notice of educational information, promotions and special offers, and/or newsletters from Mind to Muscle and Sports Medicine and Rehabilitation Centre's when they think it might be of interest to me. - I hereby give my consent to be photographed (including video photography) by Mind to Muscle for the purposes of advertising or public display. - I understand that, as explained in the Policies and Procedures for Personal Information, there are some rare exceptions to these commitments. - I agree to Mind to Muscle collecting, using and disclosing personal information about me as set out above and in the Mind to Muscle Privacy Policy. - I understand that, as explained in the Policies and procedures for personal information, there are some rare exceptions to these commitments. - I agree to Mind to Muscle collecting, using and disclosing personal information about me as set out above and in the Mind to Muscle Privacy Policy
Signature (Guardians if under 16)
*
CONSENT FOR LIABILITY
I acknowledge and fully understand that participation in fitness, training, rehabilitation, or related activities at Mind to Muscle involves inherent risks, including but not limited to the risk of injury, aggravation of a pre- existing condition, or other. I voluntarily assume all such risks and agree that Mind to Muscle, its owners, employees, contractors, and affiliates shall not be liable for any injury, loss, damage, or expense that I may sustain arising out of or in connection with my participation.
Signature (Guardians if under 16)
*
HEALTH FORM
By signing the following document, you do NOT have any of the following issues: 1. You do not have any pain in your chest when you do physical activity. 2. You do not lose your balance because of dizziness or you have never lost consciousness. 3. You do not have a bone or joint problem ( for example, back, hip, knee) that could be made worse with a change in your physical activity. 4. You are current not on any medication for blood pressure or heart condition. 5. You do not know of any other reasons why you should not do physical activity. If you answer YES to any of the above, please do NOT sign this form and discuss with your coach PRIOR to your first session. You can contact us by email at or call us at 705.737.5097
Signature
*
Cancellation Policy
Mind to Muscle Staff is only able to guarantee availability for sessions that are booked in advance. Cancellations require 24 hours' notice in advance to avoid the cancellation fee. This is to ensure that clients who are on a "wait list" may have the opportunity to attend a session. APPOINTMENTS NOT CANCELLED 24 HOURS IN ADVANCE WILL BE CHARGED Client has read the above and by signing this form understands and agrees to our 24-hour cancellation policy and refund policy, as outlined on our website under Terms & Conditions.
Signature (Guardians if under 16)
*
General Consent for Personal Information
Client First and Last Name
*
First Name
Last Name
Client Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Guardian First and Last Name
First Name
Last Name
Guardian Signature
Guardian Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Health Statements
Client First and Last Name
*
First Name
Last Name
Client Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Guardian First and Last Name
First Name
Last Name
Guardian Signature
Guardian Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Cancellation Policy
Client First and Last Name
*
First Name
Last Name
Client Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Guardian First and Last Name
First Name
Last Name
Guardian Signature
Guardian Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Consent
Submit Consent
Should be Empty: