Lw | Wellness Center Online Registration
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Wellness Center Online Registration

Registration Form
If you are under 18 years of age, please see Wellness Center staff or print the form from your printer. Parent or guardian must sign the Par-Q.
If you chose other, please explain
Please use this format xxx-xxx-xxxx
Please use this format xxx-xxx-xxxx
I know and understand the risks that are inherent while participating in the Wellness Center, including all programs and classes offered at the Wellness Center, whether on campus or streamed online, and I hereby assert that my participation is voluntary and that I knowingly assume all risks. I further understand that Palm Beach State College does not provide accident or any other form of insurance to cover illness or injuries arising out of participation, and I acknowledge that it is recommended that each participant have their own personal health coverage. I further understand that my personal/health information will not be released to any other person, except authorized personnel at the Wellness Center without approved written consent. If I become ill/injured while participating at the Wellness Center and require emergency assistance, then there can be disclosure of the health/ medical information on file to assist the attending emergency personnel.

I hereby release from liability and hold Palm Beach State College harmless from any and all claims and causes of action which might be brought by myself, parents, spouse, dependents, heirs, executors, and administrators for loss of property, personal injury or death sustained by me arising out of any activity, including participation in the Wellness Center and any classes on campus or streamed online, conducted by or under the control of Palm Beach State College. It is understood that Palm Beach State College, as used herein, shall include the employees, administrators, agents and Board of Trustees of Palm Beach State College.

By signing below I attest to having read, understood and agree to abide by the Wellness Center Rules and the Wellness Center Eligible User Rules. I understand that my Wellness Center privileges may be revoked at any time, at the discretion of the Wellness Center staff, for failure to comply with the Wellness Center Rules.
By marking checkbox I attest to having read, understood and agree to abide by the above statements.
PAR-Q & You

(A Questionnaire for People Aged 15 to 69)

 Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active.

If you are planning to become much more physically active than you are now, start by answering the seven questions in the box below. If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor.

Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly: select YES or NO.

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?

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NOTE: If the PAR-Q is being given to a person before he or she participates in a physical activity program or a fitness appraisal, this section may be used for legal or administrative purposes.
I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction.
Model Release

Do you give permission for the Wellness Center and Palm Beach State College to use any images/video of me while participating in any Wellness Center activity?

If you are under 18 years of age, please see Wellness Center staff or print the form from your printer. Parent or guardian must sign the Par-Q.

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