Fitness Fever Requirements Able to commit two to three hours a week Complete participant packet Participate in two group workouts a week and participate in one other exercise activity Program cost University of Maryland Students and SMC Campus Center URecFit Members applicants will have first priority o $50 for University of Maryland Students o $75 for SMC Campus Center URecFit Members o $125 for Non-Members (includes gym usage privileges for the duration of the program) Application Process Applications accepted Nov. 19 through Jan. 8, 2018 The packet must be completed in its entirety to be turned in All applicants will be emailed by Jan. 11, 2018 at 5pm to be informed of their acceptance status The program fee is due by Jan. 13, 2019 at 10pm. Payment will be done at the business desk No refunds will be given after the close of the Kick-off Event Upon acceptance into the Fitness Fever program, participants will receive two Group Training Session a week to be guided by personal trainers/instructors Weekly Weigh-ins Motivational Coaching and nutrition tips T-shirt Application Checklist Before submitting this application packet, please make sure the following is included: Completed Participant Application Waiver Health History PAR-Q and You Physician s Statement and Clearance form is required to be completed if YES is checked to one of more questions Photograph and Publicity Form Questions can be directed to Jimmy Mszanski, Assistant Director of Fitness jmszanski@umaryland.edu, 410-706-5355 1
Name Local Address Apt/Box # City State Zip Phone Email Male Female Weight Desired weight Height Age Student Member Other Program/Department Shirt Size S M L XL XXL XXXL How did you hear about us? AGREEMENT I agree to pay the fee by Jan.13, 2019 if selected to participate in URecFit s Fitness Fever Signature Completed applications are due to the Business Operations Desk on the 4 th floor attn: Jimmy Mszanski no later than Jan. at 5pm. Participants will be notified of acceptance into the program via email by Jan. 10, 2019 by 5pm. Some participants may be required to obtain a doctor's note prior to participating in the program. SPRING 2019 Jan - March AVAILABILITY Please list all times you are available on a weekly basis Monday: Tuesday: Wednesday: Thursday: Friday: Saturday: Sunday: Date 8 Print Name Date of Birth: / / 2
Waiver of Liability Initial: In consideration of permission to use the property, facilities, staff, equipment, services, and programs of University Recreation & Fitness ( URecFit ), I, for myself, my heirs, personal representatives or assigns, do hereby release, waive, and discharge the University System of Maryland (USM), the University of Maryland, Baltimore (UMB), URecFit, Southern Management Corporation Campus Center (SMC CC), and Wexford UMB 2, LLC (Wexford), and their regents, directors, officers, employees, and agents from liability from any and all claims, including but not limited to negligence, claims of physical or mental injury, illness (including death), and property loss arising from participation in URecFit facilities, activities, classes, and observation, and use of URecFit facilities, premises, and equipment. Assumption of Risk Initial: Physical activity, by its very nature, carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. URecFit and UMB have facilities for, and provides for, activities such as weight lifting, running, aerobic activities, group fitness, classes, instructional, outdoor adventure, and sporting activities. Some of these involve strenuous exertions, some involve quick movements, and others involve sustained physical activity, which places stress on the cardiovascular system. Specific risks vary from one activity to another, but the risks range from (1) minor injuries such as scratches, bruises, and sprains; (2) major injuries such as eye injury or loss of sight, joint or back injuries, heart attacks, and concussions; (3) catastrophic injuries including paralysis and death. I understand the risks that are inherent in activities made possible by URecFit. I agree that my participation is voluntary and I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of URecFit or others, and I assume full responsibility for my participation. Indemnification and Hold Harmless Initial: I agree to indemnify and hold harmless the USM, UMB, URecFit, SMC CC, Wexford, and their regents, directors, officers, employees, and agents, from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney s fees, for claims related to my involvement at URecFit sponsored activities. Severability Initial: I agree that this Waiver of Liability, Assumption of Risk, and Indemnification Agreement may be broadly construed in favor of URecFit as permitted by the law of the State of Maryland and that if any portion of this Agreement is held invalid, the balance shall continue in full legal force and effect. Acknowledgment of Understanding I certify that I am at least eighteen (18) years of age, and that I have read and I understand this Agreement as indicated by my initials above and my signature below. I acknowledge that I am signing this Agreement freely and voluntarily, and intend by my signature to provide a complete and unconditional release of all liability. If I do not agree to any of the terms of this Agreement, I understand I do not need to sign it, and I may forego participating in the facilities and activities of URecFit as the alternative. READ AND UNDERSTOOD: Signature: Date: / / If the person is under 18 years of age: The Applicant is under 18 years of age; he or she must also have a Parent or Guardian s signature to participant. This entire form is Read and Understood by the Parent/Guardian. 3
PERSONAL MEDICAL HISTORY Physician s Name Health History Physician s Number Have you had any past operations, hospitalizations, disabilities, diseases or are you currently under a physician s care: Have you ever been diagnosed with the following? Please check all that apply and write the date and a description below. Date and Description Heart Attack High Blood Pressure High Cholesterol Rheumatic Fever Heart Murmur Seizure/epilepsy Stroke High Blood Triglycerides Blood Clots Cancer Diabetes Asthma Gout Arthritis Osteoporosis Exercise-induced Asthma Thyroid Disorders Allergies Varicose Veins Hernia Obesity Anorexia Bulimia Severe Headaches Kidney Failure Kidney Removal Kidney Stones Kidney Dialysis Colitis Gall Bladder Removal Fibromyalgia Anemia Pregnancy Gall Bladder Disease/stones 4
SYMPTOMS REVIEW Have you ever experienced the following during exercise, after exercise or during a resting state? Please check all that apply. Shortness of breath or wheezing Side aches or side stitches Middle back pain Extremely high heart rate Irregular heart rate Shoulder pain Sharp Chest Pain Dull aching chest pain Foot or ankle pain Overall or one-sided weakness Loss of coordination Knee pain Heat intolerance Dizziness Low Back pain Mental Confusion Fainting Calf pain Vomiting Swelling of ankles or hands Hip pain/sciatica Cramping Shin Splints Arm or neck pain MEDICATIONS Please check all that apply and describe side effects Digitalis Anti-arrhythmias Diuretics and Electrolytes Metabolics Beta Blockers Tranquilizers or sedatives Vasodilators Alpha Blockers Calcium Channel Blockers Other Anti-inflammatory (Motrin, Advil) INJURY HISTORY Have you ever suffered an injury at any of the following joints? If yes, please describe severity and frequency. Ankle (R or L) Knee (R or L) Hips Low Back Shoulder (R or L) 5
Neck Other Do any of the joints above bother you during exercise? Yes, please explain below No FAMILY HISTORY Please check if anyone in your immediate family (grandparents, parent, and siblings) experienced any of the following. Relationship Age Description Heart Attack or stroke before age of 55 Heart Surgery High Cholesterol High Blood Pressure High Blood Triglycerides Diabetes Cancer Alzheimer s Heart Operations Congenital Heart Disease Early death Other family illness LIFE STYLE QUESTIONAIRE Please check all that apply. Do you smoke? No Yes Former Smoker If you checked yes please select from the following Cigarettes Cigar Pipe If you checked any of the following, how many do you smoke a day? If you checked any of the following, how many years have you smoked? If you checked the following, how long ago did you stop smoking? Do you drink alcoholic beverages? Yes No 6
If you checked yes to the above question, how much do you drink (in ounces) in an average week? Do you drink caffeinated beverages? Yes No If you checked yes to the above question, how many cups a day? Please rate your Daily Stress Levels (select one) Low Moderate High-but I enjoy the challenge High-sometimes difficult to handle High-often difficult to handle Describe what you eat on a typical day, give specific examples and included time of day. Breakfast Lunch Dinner Other Recent Exercise Habits How many times per week are you physically active? When you are physically active, how long does it last? On a scale from 1 to 10, how intense is your typical activity? (10 being highest) How many years have you been exercising? In a typical week, how many minutes do you spend in the following activities? Running/jogging: Racquet Sports: Biking: Yoga: Walking: Swimming: Skiing: Pilates: Aerobics: Weight Training: Stair Climbing: 7
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Physician s Statement and Clearance Form Licensed Medical Physician s clearance to participate in a progressive exercise program is requested for: Client s Name: Date of Birth: Physician s Name: Physician s Phone: The University of Maryland, URecFit s Fitness Fever Program provides a variety of fitness opportunities for the University community. These activities may be vigorous in nature and are usually challenging to the individual s cardio respiratory and muscular systems. The individual may be involved in a class, personal training and/or self directed type of exercise program. It is my understanding that will be participating in a fitness evaluation and/or exercise program. I understand that the aspects of the program will include the following. 1 Physiological tests including: 1. Resting heart rate and blood pressure 2. Body composition (skin folds) 3. Abdominal Strength: Curl-ups and Push-ups 4. Cardiovascular testing 5. Flexibility: Sit and Reach 6. Other: 2 Exercise program including: 1. Strength training using weights, body weight, bands, etc. 2. Cardiovascular exercise 3. Other: Please list any recommendations or restrictions that are appropriate for your patient in this exercise program: As the individual s attending physician, I am not aware of any medical condition that would prevent him/her from participation in the exercise outlined above. Physician s Signature Date Phone Thank you for taking the time to fill this out. Please return the form to: URecFit Jimmy Mszanski Assistant Director Fitness 621 W Lombard St, Room 509 Phone: (410) 706-5355 Fax: (410) 706-1472 9
Photograph and Publicity Agreement Form I,, give the UM URecFit permission to use my name, likeness, image, voice, and/or appearance as such may be embodied in any pictures, photos, video recordings, audiotapes, digital images, and the like, taken or made on behalf of UM URecFit. I agree that UM URecFit have complete ownership of such pictures, etc., including the entire copyright, and may use them for any purpose consistent with the URecFit missions. These uses include, but are not limited to illustrations, bulletins, exhibitions, videotapes, reprints, reproductions, publications, advertisements, and any promotional or educational materials in any medium now known or later developed, including the Internet. I acknowledge that I have read and I understand this Agreement above as indicated by my signature below. I acknowledge that I am signing this Agreement freely and voluntarily. If I do not agree to any of the terms of this Agreement, I understand I do not need to sign it, and I may forego participating in the facilities and activities of URecFit as the alternative. READ AND UNDERSTOOD: Signature Dat 10
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