Thank you for choosing the Warm Aquatic Therapy Classes at the Peace Arch Hospital with JR Rehab Services. We request your understanding and cooperation in maintaining both your and our safety and health by reading and agreeing to the following informed consent.
I hereby consent to voluntarily engage in Community Warm Aquatic Therapy Classes.
I understand that each person, (myself included), has a different capacity for participating in such activities, facilities, programs, and services. I am aware that all activities, services, and programs offered are educational, recreational, or self-directed in nature. I assume full responsibility, during and after my participation, for my choices to use or apply, at my own risk, any portion of the information or instruction I receive.
I have been informed that during my participation in this exercise class, it is my obligation to stop exercising if I experience any symptoms such as pain, fatigue, shortness of breath, chest discomfort, or similar occurrences. It is also my obligation to stop exercising if I experience back pain, neck pain or any other pain. I have been advised that at any time it is my complete right to decrease or stop exercise and that it is my obligation to inform the program personnel of any symptoms I may have. I hereby state that I have been so advised and agree to inform the program personnel of my symptoms, should any develop.
I understand and have been informed that there are inherent risks in participating in activities in the water including but not limited to drowning, slips, falls and even entrapment by hair, limb or mechanical items such as jewelry and bathing suit strings. I agree to follow the safety rules as outlined at any time by the instructor or attendant and on signs around the pool area. I further agree to inform the staff of any potential problems I may have or notice, which may affect the safety of myself or someone else.
I understand and have been informed that there exists the remote possibility during exercise of adverse changes including abnormal blood pressure, fainting, disorders of heart rhythm, and very rare instances of heart attack or even death. I have been told that every effort will be made to minimize these occurrences by proper staff attention to my feedback of my physical condition before each exercise session, by staff supervision during exercise, and by my own careful control of my exercise efforts. I understand that there is a risk of injury, heart attack, or even death as a result of my exercise, but knowing those risks, I desire to participate as herein indicated.
I understand that this program may or may not benefit my physical fitness or general health. I recognize that involvement in the exercise sessions will allow me to learn safe and beneficial ways to perform certain exercises.
I have been given an opportunity to ask certain questions as to the procedures of this program. I acknowledge that I have read this document in its entirety or that it has been read to me if I have been unable to read same. I consent to the rendition of all services and procedures as explained herein by all program personnel.
