55+/Senior Fit Membership Form

Transcription

1 55+/Senior Fit Membership Form Today s Date: Name: Address: City/State/Zip Date of Birth (optional) Gender: Female Male Home Phone: Cell Phone: Work Phone: address: Name, Address and Phone number of contact person: Race (Optional): African American Asian Caucasian Latino Other Marital Status: Divorced Married Single Widowed Physician Name: Physician Address & Phone: Does not have a physician or a medical home How do you get information? TV Radio Newspaper Internet Indicate all areas for which patient would like more information: Advance Directives Assisted or Skilled Nursing Facilities COPD/Lung Disease Dementia Depression Diabetes Management Financial Planning

2 Gardening Heart Disease High Blood Pressure Independent Senior Living Medicare/Supplemental Insurance Mentoring Nutrition Parenting Grandchildren Stroke Tobacco/Alcohol/Substance Abuse Wills Visiting Nurse/Medical Home Care Volunteer Opportunities Other topics/questions: Do you still drive? Yes No Do you have a pet? Yes, List type: No Do you attend church regularly? Yes No List any social activities in which you participate: (volunteer, clubs, civic organizations, etc.) What do you do for fun? How often do you exercise: Never Occasionally Regularly 3x/week Often 5+ /week I consider my health to be Excellent Very good Good Fair Poor Veteran of the United States Armed Forces? Yes No Hospital of Choice: How did you hear about 55+? A friend Doctor: A brochure, list location: Other: Return to: John Bruinsma, Saint Joseph Health System, Senior Services Navigator 215 W. 4 th St., LL 201, Mishawaka, IN ; fax: ; john.bruinsma@sjrmc.com

3 Participant Annual Information Release - Senior Fit (This Participant Annual Information Release AND a Health Care Provider Consent MUST be completed prior to participation in Senior Fit exercise.) I understand that this physical fitness program is a group exercise activity that may include exercises to build the cardiorespiratory system, (heart & lungs), and the musculoskeletal system (muscle endurance, strength, and flexibility). Components may include but are not limited to low impact aerobics, strength training, stretching, balance and coordination exercises. Twice per year a fitness assessment is offered to measure progress. I acknowledge that all fitness tests undergone are done merely for informational purposes and do not declare my fitness, or lack of fitness for participation in the Senior Fit program. There are potential risks with any exercise program. I hereby certify that I know of no medical problems and accept any risk of illness or injury as a result of my participation in this exercise program. I understand that it is my responsibility to inform the class instructor(s) of any medical condition(s) that I may have. Furthermore, I agree to wear appropriate exercise clothing and supportive athletic shoes to class. I understand that clogs, sling-back shoes, sandals and bare feet are not allowed. I hereby release and hold harmless, (the site/location owner/operator of the exercise program); and Saint Joseph Health System, their agents, employees and independent contractors from any and all liability, damage, expense, causes of action, suits, claims, or judgments arising from injury, damage or loss to me or my personal property which may arise from my participation in this exercise program. Name: Address: City: State: Zip Code: Phone: (day) (evening) Race (OPTIONAL) Date of birth: SENIOR FIT LOCATION(S): TIME(S) OF CLASS: Emergency Contact Name: Relationship: Phone number: Cell number: Participant s Signature: Return to: Outreach Services- SJHS Senior Fit Program, 215 W. 4 th St., LL 201, Mishawaka, IN 46544

4 Senior Fit In an emergency, the facility location staff will take the necessary steps to ensure your safety, which could mean contacting an available doctor and/or 911 services. Information on this card may be shared with staff on a need to know basis. Signature of participant: Date: Emergency Contact Information Your Name Address Phone numbers Office use EMERGENCY Contact Name Emergency Contact Address Emergency phone numbers Emergency and Medical Information Physician Name Physician s Phone Hospital of choice Medications Medications Continued Medications Continued List any health conditions Mail to: John Bruinsma, Community Outreach, 215 W. 4 th St., Mishawaka, IN Or Fax to

5 HEALTH PROVIDER GIVES CONSENT TO PARTICIPATE Name of Patient: I hereby consent to the participation of the above named individual in the senior exercise program. I am unaware of any medical or surgical condition(s), which the individual possesses which would be considered a contraindication to exercise. Please note any recommendations or restrictions appropriate for your patient in the exercise program: (All fields required) Physician s Name (printed or typed): Physician s Signature: Date: Physician s Phone: Physician s Address: City: State: Zip Code: Fax completed form to: (574) Attention: John Bruinsma Senior Services Navigator (Phone ) OR Mail to: John Bruinsma Outreach Services- SJRMC Senior Fit Program 215 W. 4th St., LL 201 Mishawaka, IN 46544