HUMBOLDT STATE UNIVERSITY RELEASE AND WAIVER OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT

(Please read, sign, and date bottom)

For the good and valuable consideration, including permission to participate in all Employee Wellness class offerings at Humboldt State that any employee would be participating in, I (for myself and my successors):

1) Acknowledge that I fully understand that my participation may involve risk of serious injury or death, including economic losses;
2) Assume any and all risk of personal injuries to myself, including medical or hospital bills, permanent or partial disability, death, and damages to my property, caused by or arising from my participation in this event or activity;
3) Release, waive, discharge, and relinquish Humboldt State University and their representatives from any claim against them arising from my participation where same shall arise by their negligence or otherwise;
4) Warrant that I am in good health and have no physical condition that would prevent me from participating in this activity.

THIS DOCUMENT RELIEVES HUMBOLDT STATE UNIVERSITY AND OTHER FROM LIABILITY FOR PERSONAL INJURY, WRONGFUL DEATH, AND PROPERTY DAMAGE CAUSED BY NEGLIGENCE. I HAVE READ THIS DOCUMENT, AND UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN VOLUNTARILY.


 Printed Name

 Signature

 Date

 __________________________

 _________________________

 _________________________

IMPORTANT:

NEW MEMBERS MUST FILL THIS OUT OR IF NECESSARY PLEASE UPDATE!!

Humboldt State University
Health and Wellness Institute Medical Information and History

Name:_________________________________________________________________________ Address:_______________________________________________________________________
Home Phone:_____________________ Work Phone:___________________________________
Age:_______ Date of Birth:_____________
Student ( ) Staff/Faculty ( ) Community ( ) Athlete ( )
Date of last medical examination:___________________________________________________

YES NO Risk Factors
( ) ( )   1. Are you currently under the care of a physician?
( ) ( )   2. Do you have diabetes?
( ) ( )   3. Have you been told you have high blood pressure (>140/90)?
( ) ( )   4. Have you been told your cholesterol > 200mg/dl?
( ) ( )   5. Do you smoke?
( ) ( )   6. Has anyone in your immediate family died of a heart attack, or stroke?
( ) ( )   7. Do you exercise? If so explain.
If you answered yes to any of these questions, please explain.

YES NO Signs/Symptoms.
( ) ( )   8. Do you ever have pains in your chest/heart during or after exercise?
( ) ( )   9. Do you ever feel faint or have dizzy spells?
( ) ( ) 10. Have you ever had, or has your doctor ever diagnosed you with an irregular heart rate or a heart murmur?
( ) ( ) 11. Do you ever have shortness of breath at rest or with mild exertion?
( ) ( ) 12. Do you experience heart palpitations or rapid heart rate when resting?
If you answered yes to any of these questions, please explain.

Office use only: ____Low Risk ____Moderate Risk ____High Risk


YES NO Health Related Questions.
( ) ( ) 13. Have you recently had surgery or a major illness?
( ) ( ) 14. Do you have any physical limitations during exercise?
( ) ( ) 15. Are you pregnant?
( ) ( ) 16. Do you have any allergies to medications, bees, foods, etc.?
( ) ( ) 17. Are you currently taking any medications, supplements or pills?
( ) ( ) 18. Do you have asthma and/or do you use an asthma inhaler?
( ) ( ) 19. Do you have any skin problems?
( ) ( ) 20. Have you had any caffeine today?
( ) ( ) 21. Have you exercised today?
If you answered yes to any of these questions, please explain.

What are your health and fitness goals?

I certify that the information I have provided is complete and accurate to the best of my knowledge.

Date:_______________________________

Signature of Subject:_______________________________________________

Date:_______________________________

Signature of Witness:_______________________________________________