CFA Registration :: Marsh Brook Rehab

Important Notice *

You must read and acknowledge the following before continuing! Online registration is permitted only by participants who are at least 18 years of age, or by the parent or legal guardian of a minor participant (under 18).

I Agree

Person Completing Registration *

Self

Parent/Legal Guardian of a Minor

Last Name *

First Name *

Middle Initial

Parent’s/Legal Guardian’s Name (If registering a minor) *

Address *

City *

State *

Zip *

Cell Phone *

Home Phone *

Email Address *

Birth Date *

Gender *

Male

Female

Emergency Contact Name *

Emergency Contact Relationship *

Cell Phone *

Home Phone *

Emergency Contact Address *

Past Medical History

If you select “YES” to any of the questions in the shaded areas, the CFA may require a physician note prior to starting a training program.

Heart Disease *

Yes

No

Stroke *

Yes

No

Diabetes *

Yes

No

Heart Murmur/Palpitations *

Yes

No

Heart Attack *

Yes

No

Kidney Disease *

Yes

No

Epilepsy or Seizures *

Yes

No

High Blood Pressure (uncontrolled) *

Yes

No

Cancer *

Yes

No

Pneumonia *

Yes

No

Emotional Disorders *

Yes

No

Joint Pain/Stiffness *

Yes

No

Parkinson’s Disease *

Yes

No

Recurrent Cough *

Yes

No

Anxiety/Depression *

Yes

No

Previous Surgery *

Yes

No

Multiple Sclerosis *

Yes

No

Asthma *

Yes

No

Trouble Sleeping *

Yes

No

Arthritis *

Yes

No

Peripheral Vascular Disease *

Yes

No

Chest Discomfort *

Yes

No

Fatigue/Lack of Energy *

Yes

No

Neck Problems *

Yes

No

Emphysema/Short of Breath *

Yes

No

Stomach Problems *

Yes

No

Light Headedness/Fainting *

Yes

No

Back Problems *

Yes

No

Phlebitis or Emboli *

Yes

No

Migraine/Recurrent Headaches *

Yes

No

Rheumatic Fever *

Yes

No

Hernia *

Yes

No

Anemia *

Yes

No

Low Blood Pressure *

Yes

No

Medical Condition (Other)

Hospitalization

Allergies

Are you on any medications? *

Yes

No

Medications *

Liability Waiver *

I understand that Marsh Brook Rehab’s Strength and Conditioning Program (“Program”) is designed for, and intended to be used by, individuals in good health and that participating in it may be harmful to individuals with certain medical conditions. Accordingly, I certify that I have discussed my participation in the Program with my physician, consulted with my physician about any health-related concerns I have regarding my participation in the Program, and have received medical clearance from my physician to participate in the Program. I also understand that engaging in any exercise or sporting activity creates an unavoidable risk of injury or illness. Furthermore, I understand that the risk of injury or illness is increased if I fail to take reasonable steps to ensure my well-being while participating in the Program. Accordingly, I agree that I will take reasonable steps to ensure my well-being while participating in the Program including, but not limited to, engaging in proper warm-up and cool down activities; using the Program’s equipment properly; following the recommendations of the Program’s staff; and adhering to the Program’s rules. I understand and agree that I am participating in the Program and using the facility and equipment at my own risk and agree to hold Strafford Health Alliance, d/b/a Marsh Brook Rehab, as well as its principals, employees, and agents, harmless and free from any liability relating to my participating in the Program and/or use of the facility or equipment. I further agree that I will indemnify and hold harmless Strafford Health Alliance, d/b/a Marsh Brook Rehab, as well as its principals, employees, and agents, from any claims asserted relating to my participation in the Program and/or use of the facility or equipment. I certify that: (1) I am at least 18 years of age; (2) I have read the contents of this WAIVER; (3) the Participant has received medical clearance to participate in the Program; and (4) the Participant is mature enough to participate in the Program, understand the risks inherent in the Program’s activities, and take reasonable steps, including but not limited to those listed above, to ensure his/her well-being while participating in the Program. On behalf of the Participant and myself, I agree to hold Strafford Health Alliance, d/b/a Marsh Brook Rehab, as well as its principals, employees, and agents, harmless and free from any liability relating to the Participant’s participation in the Program and/or use of the facility or equipment. I further agree that I will indemnify and hold harmless Strafford Health Alliance, d/b/a Marsh Brook Rehab, as well as its principals, employees, and agents, from any claims asserted relating to the Participant’s participation in the Program and/or use of the facility or equipment.

I Agree

Photography Authorization *

I give my permission to Marsh Brook Rehab to photograph my person for the express purpose of promoting all aspects of Marsh Brook Rehab and any other use of this form is prohibited. Original photograph(s) will be filed with strict confidence during its use in the same confidential manner as other personal records and I may inspect or obtain a copy of the protected information described by this authorization. I understand that Marsh Brook Rehab shall not condition training, payment, or enrollment in the Center for Athletes on my providing authorization for the requested use or disclosure AND THAT I MAY REFUSE TO SIGN THIS AUTHORIZATION. I understand that this authorization may be revoked in writing and delivered to Marsh Brook Rehab at any time for further disclosure of the hard copy although revocation will not affect the disclosure of records whose release I have previously authorized. I understand that information used or disclosed pursuant to this authorization could be subject to re-disclosure by the recipient, and if so, may not be subject to federal or state law protecting its confidentiality.

I Agree

I Refuse

Would you like to receive a call from a CFA staff member to schedule appointments? *

Yes

No

Have you already scheduled appointments with a CFA staff member? *

Yes

No

Are you registering as part of a team or group? *

Yes

No

Team Name *