I acknowledge that my answers to these questions are

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
I acknowledge that my answers to these questions are true and complete. I will immediately inform
the exercise instructor of any changes in my health.
Signature: __________________________________________ Date: __________________
From Carol Kennedy-Armbruster and Mary M. Yoke, 2014, Methods of Group Exercise Instruction, 3rd ed. (Champaign, IL: Human Kinetics).

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Appendix D
Informed Consent and Agreement Form
I desire to engage voluntarily at _______________________________ (name of program, club, or agency)
to improve my physical fitness.
I know that I am required to fill out a health and lifestyle questionnaire before I begin to exercise.
The information obtained from the questionnaire will be used in the following ways:
• To indicate any cardiac risk or other reason why I should not exercise based on the ACSM
guidelines
• To determine the need for a physician’s evaluation and written approval before I enter the
exercise program
• To recommend the types of exercise I should concentrate on to reach my fitness goals and the
types of exercises I should avoid
I understand that my participation in the program may not benefit me directly in any way. I realize
that the program may help me evaluate my lifestyle, choose the activities I may safely carry out, and
increase my quality of life.
I also understand that the reaction of the body to activity cannot always be predicted with complete
accuracy. The changes that may occur and are associated with physical activity include, but are not
limited to, the following signs and symptoms:
• Abnormal blood pressure or heart rate responses
• Breathlessness
• Chest discomfort
• Muscular or skeletal injury
• Heart attack and death, in very rare instances
I realize my responsibility in recognizing these potential hazards; monitoring myself before, during,
and after exercise; and seeking help in the event of injury, if possible. I will attend the orientation
session and talk to my personal trainer or exercise instructor to learn how to minimize these potential
hazards and what I should do in an emergency. I understand that I can minimize my risk during exercise
by following these steps:
• I will give priority to regular attendance.
• I will not withhold any information pertinent to my health from the instructor or supervisor in
charge of the program, and I will immediately update my health and lifestyle questionnaire if
changes in my medication or status occur.
• I will report any unusual symptoms or problems that I experience before, during, or after exercise.
• I will follow the amounts and types of activities recommended during the orientation session.
• I will not exceed my target heart rate.
• I will not exercise when not feeling well or for 2 hours after eating a large meal, smoking a cig-
arette, drinking alcohol, or taking over-the-counter medications or street drugs.