I desire to engage voluntarily in the Brushy Creek Community Center exercise program in order to attempt
to improve physical fitness. I understand that the activities are designed to place a gradually increasing
workload on the cardio respiratory system and to thereby attempt to improve its function. The reaction of
the cardio respiratory system or such activities can’t be predicted with complete accuracy. There is a risk
of certain changes that might occur during or following the exercise. These changes might include
abnormalities of blood pressure or heart rate.
I understand that the purpose of the exercise program is to develop and maintain cardio respiratory fitness,
body composition, flexibility and muscular strength and endurance. A specific exercise plan will be give to
me, based on my needs and interests and my doctor’s recommendations. All exercise programs include
warm-up, exercise at target heart rate and cool-down. The programs may involve walking, jogging,
swimming, or cycling (outdoor and stationary); participation in exercise fitness, rhythmic aerobic exercise,
or choreographed fitness classes; or calisthenics or strength training. All programs are designed to place a
gradually increasing workload on the body in order to improve overall fitness. The rates of progression are
regulated by exercise, target heart rate and perceived effort of exercise.
I understand that I am responsible for monitoring my own condition throughout the exercise program, and
should any unusual symptoms occur, I will cease my participation and inform the instructor of the
symptoms.
In signing this consent form, I affirm that I have read this form in its entirety and that I understand the
nature of the exercise program. I also affirm that my questions regarding the exercise program. I also
affirm that my questions regarding the exercise program have been answered to my satisfaction.
In the event that a medical clearance must be obtained prior to my participation in the exercise program, I
agree to consult my physician and obtain written permission from my physician prior to the commencement
of any exercise program.
Also, in consideration for being allowed to participate in the Brushy Creek Community Center exercise
program I agree to assume the risk of such exercise, and further agree to hold harmless the Brushy Creek
Community Center and its staff members conducting the exercise program form any and all claims, sits,
losses, or related causes of action for damages including, but not limited to, such claims that my result from
my injury or death, accidental or to otherwise during, or arising in any way from the exercise program.
The District is obligated under the Texas Open Records Act to give out personal and private information on customers (such as name, address, telephone number, social security, etc.). Under the act this information is accessible to salesman, bill collectors, disgruntled spouses, telephone solicitors, junk mail listings or anyone else that may want to know about you and your account. If you DO NOT want any information given out regarding you or your account, please check the box below.
I (we) request that under the Privacy Act, the District not release any information.