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Consent (Southeastern Louisiana University)

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Informed Consent
Program Objectives
I _______________________ understand that this physical fitness program is
individually tailored to meet the goals and objectives agreed upon by the Program Coordinator(s)
and myself. I understand, however, that the Program Coordinator(s) or physical fitness program
cannot guarantee that I will accomplish the established goals.
Description of Exercise Program
I ________________________ understand that the exercise program will involve
participation in a number of types of fitness activities. These activities will vary depending upon
the established objectives, but will probably include:
1) Aerobic activities including, but not limited to, the use of treadmills, stationary bicycles,
step machines, rowing machines, and running track;
2) Muscular endurance and strength building exercises including, but not limited to, the use
of free weights, weight machines, calisthenics, and other exercise apparatus; and
3) Selected physical fitness and body composition tests.
Description of Potential Risks
The Program Coordinator(s) explained that no exercise program is without inherent risks
and that, regardless of the care taken by the Program Coordinator(s) and/or fitness instructors, he
(or she) cannot guarantee my personal safety. For example, when one induces cardiovascular
stress through activity, injuries can range from minor injury (e.g., pulled muscles) to less
frequent serious injury (e.g., heart attack, stroke, or other cardiovascular accidents) to the rare
catastrophic incident (e.g., death, paralysis).
I ________________________ realize that when participating in any exercises or
conditioning activity, there is always a possibility of minor injuries as well as a slight possibility
of major injuries or catastrophic injury/death.
Description of Potential Benefits
I _______________________ understand that a regular exercise program has been shown
to have definite benefits to general health and well-being. I know that some of the physiological
benefits of a regular exercise program can include loss of weight, reduction of body fat,
improvement of blood lipids, lowering of blood pressure, improvement in cardiovascular
function, reduction in risk of heart disease, improved strength and muscular endurance, improved
posture, and improved flexibility. I further understand that regular exercise can have
psychological benefits, often improving one’s outlook and feeling of well-being, as well as
relieving tension and stress.
Client Responsibilities
I _____________________ understand that it is the responsibility of client to:
1) Fully disclose any health issues or medications that are relevant to participation in a
strenuous exercise program;
2) Inform the trainer if there are activities with which I do not feel comfortable;
3) Cease exercise and report promptly any unusual feelings (e.g., chest discomfort, nausea,
difficulty breathing); and
4) Clear my participation in an exercise program with a physician.
Client Acknowledgements
In agreeing to this exercise program, I ______________________:
• Acknowledge that my participation is completely voluntary.
• Understand that the potential physical risks involved in the exercise program and believe
that the potential benefits outweigh those risks.
• Give consent to certain physical contact that may be necessary to ensure proper technique
and body alignment.
• Understand that the achievement of health or fitness goals cannot be guaranteed.
• Have had a voice in planning and approving the activities selected for the exercise
program.
• Have been able to ask questions regarding any concerns and have had those questions
answered to my satisfaction.
• Acknowledge that I am in good physical condition, have no impairment which might
prevent participation in such activities, and have been advised to consult a physician prior
to beginning this program.
• Have been advised to cease exercise immediately if I experience unusual discomfort and
feel the need to stop.
Privacy
I ___________________ understand that my personal information, or any information
disclosed in this registration packet will be kept confidential, and will only be shared with
essential personnel as a need to know basis.
I ___________________ have read and understand that above agreement. I have been
made fully aware of and understand the potential risks involved in this physical fitness program.
I hereby consent to those risks and assert that I am freely and voluntarily participating in this
program.
Finally, I am freely signing this agreement.
____________________ ________ _____________________ ________
Signature of Client Date Signature of Trainer Date
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Consent (Southeastern Louisiana University)

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Completed 20 July 2020

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