As part of the Faculty/Staff Exercise Program, I understand that I will be asked to perform various tests to evaluate my level of physical fitness. I understand these tests will be administered by myself and/or others in the program. I am also aware that the administration and performance of such tests are designed to be an educational experience.

I understand that I am free to ask any questions about any tests performed. If for any reason I am unable to perform a given test, I will inform the Program Coordinator.

There are certain risks associated with any physical fitness evaluation. These include abnormal blood pressure or heart rate responses, heart beat disorders, fainting, and, in rare cases, heart attack, stroke, or death. Every effort will be made to minimize these risks by evaluation of preliminary information relating to my health status and by observation of symptoms during exercise tests.

Because my health status can directly affect my safety during exercise, I will disclose any problems about my health status to the Program Coordinator. I will also promptly report any feelings of discomfort or pain associated with a given test.

This information about me is confidential and will not be disclosed to anyone but the Program Coordinator.

My consent to participate in this testing is voluntary and I realize that I am free to withdraw from any test, at any time, for health reasons. If I have further questions regarding this experience I am free to contact the Program Coordinator at 931-2219.

I have read this form and given written consent to participate in this laboratory experience.

Date:

Participant Signature:

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