Medical Consent And Release Forms -City Of Louisville

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Medical Consent and Release Forms
Informed Consent Form
I, _________________________, hereby give informed consent to engage in a series of procedures relative to
taking a battery of physical fitness tests. The purpose of the testing is to ascertain my level of physical fitness
for job task performance capability. The test will measure the following abilities:
Walking for extended periods of time
Using hands and feet in use of force situations
Short sprints
Bending, stooping and reaching
Running up and down stairs
Moving people and objects
There always exists the possibility that certain detrimental physiological changes may occur during testing and
activity. The reaction of the cardio respiratory and muscular systems to such activities can’t be predicted with
complete accuracy. These changes could include heat related illnesses, orthopedic injuries, abnormal
cardiovascular conditions (heartbeat, blood pressure) and in rare instances, a heart attack or risk of death.
I have read this form and understand there are inherent risks associated with any physical activity. I understand
that I am responsible for monitoring my own condition throughout the testing and should any unusual
symptoms occur, I will cease my participation and inform the monitor.
To the best of my knowledge, I do not have any health contraindications to participate in this testing. In signing
this consent form, I affirm that I have read this form in its entirety and that I understand the nature of this
testing. I also affirm that my questions regarding the tests have been answered to my satisfaction.
Therefore, in consideration for being allowed to participate in this testing, I do hereby voluntarily and
knowingly assume the risk of such testing and I, with the intention of binding myself, my spouse, my heirs,
legal representatives and assign do hereby voluntarily and knowingly release and forever discharge, indemnify
and hold harmless the City of Louisville Metro, Kentucky, its officials and employees conducting or related to
the testing from any and all claims, suits, losses or related causes of action for damages, including, but not
limited to, such claims that may result from my injury or death, accidental or otherwise, during or arising in any
way from this testing.
I have read and fully understand the provisions of this release, and I have voluntarily, knowingly and
intelligently executed said release and indemnification agreement with the express intentions of effecting the
extinguishments of the claim and liabilities herein designated and establishing the agreements herein.
__________________________________
_____________________________
Signature of Participant
Date
__________________________________
_____________________________
Signature of Witness
Date

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