Campus Recreation Instructional Program Registration

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This information may be considered when reviewing your membership application but may not automatically eliminate your ability to participate. Have you ever been convicted of a felony? Yes No

Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active.

If you are planning to become much more physically active than you are now, start by answering the seven questions in the box below. If you are between the ages of 16-59, the Par-Q will tell you if you should check with your doctor before you start. If you are over 59 years of age, and you are not used to being very active, check with your doctor.

Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly. Check YES or NO.
	Yes	No
Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?	Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?Yes	Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?No
Do you feel pain in your chest when you do physical activity?	Do you feel pain in your chest when you do physical activity?Yes	Do you feel pain in your chest when you do physical activity?No
In the past month, have you had chest pain when you were not doing physical activity?	In the past month, have you had chest pain when you were not doing physical activity?Yes	In the past month, have you had chest pain when you were not doing physical activity?No
Do you have a bone or joint problem that could be made worse by a change in your physical activity?	Do you have a bone or joint problem that could be made worse by a change in your physical activity?Yes	Do you have a bone or joint problem that could be made worse by a change in your physical activity?No
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?	Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?Yes	Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?No
Do you know of any other reason why you should not do physical activity?	Do you know of any other reason why you should not do physical activity?Yes	Do you know of any other reason why you should not do physical activity?No

If you answered NO to all questions, you can be reasonably sure you can: Start becoming much more physically active-begin slowly and build up gradually. This is the safest and easiest way. Take part in a physical appraisal-this is an excellent way to determine your basic fitnesss so that you can plan the best way for you to live actively. I understand

Delay becoming much more active: If you are not feeling well because of a temporary illness such as a cold or fever-wait until you feel better. If you are pregnant-talk to you doctor and have them complete a Physican's approval form before you start becoming more active. Please note: If your health changes so that you then answer YES to any of the above questions, tell your fitness or health professional. I understand

By signing this document, I acknowledge that I have voluntarily chosen to participate in a program of progressive physical activity.  In signing this document, I acknowledge being informed of the strenuous nature of the program and the potential for unusual, but not impossible, physiological results including but not limited to abnormal blood pressure, fainting, heart attack, or death.

By signing this document, I assume all risk for my health and well-being and hold harmless of any responsibility the instructor, facility or any persons involved with program or testing procedures and recommendations are encouraged and welcomed.

On behalf of myself, my family, heirs, and personal representatives, I hereby release SUNY Brockport, its trustees, Board of Regents, officers, employees, and agents from any liability for the injuries or death sustained by me as a result of my participation in the activities of the above named organization.

I also agree to indemnify and hold harmless the University, its trustees, Board of Regents, officers, employees, agents from any liability for damage or injury to others which may occur as a result of my participation in the activities of the above named organization.

I acknowledge that I have read this content carefully, and understand the terms and requirements and fully agree to all considerations herein.
If you agree to the above statements, use a computer mouse or stylus to sign your signature in the signature pad.

If the participant is under the age of 18, a parent or legal guardian needs to sign in the signature pad.