Fitness Assessment Template & Personal Training Registration Packet (Page 6 of 7) in pdf

Fitness Assessment Template & Personal Training Registration Packet Page 6

MEDICAL INFORMATION RELEASE

Each participant in the Fitness Assessment and Personal Training Program must complete the following sections,

even though physician approval may not be necessary in every case. All men over the age of 45 years old and

women over the age 55 years old must obtain physician approval.

If medical clearance is necessary in your case, the Fitness & Wellness Graduate Associate will contact you and will

complete a physician’s approval form which you will need to pick up from the Campus Recreation office. This

form must be completed by your physician and returned to the Campus Recreation office.

I hereby give my physician permission to release any pertinent medical information from my medical records to the

Campus Recreation staff of Springfield College. I understand that this information will be kept confidential. I am

aware that this release will expire within one year of signature and that I may revoke the medical release at any

time.

Participant’s Name: _________________________________

Date of Birth: ___________

Participant’s Signature: ______________________________

Today’s Date: __________

Physician Information

Name of Physician(s)

Address

Contact Numbers

Phone:

Fax:

Phone:

Fax:

Phone:

Fax:

Fitness Assessment Template & Personal Training Registration Packet Page 6