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A Healthy Downstate Informed Consent

Last Name First Name Extension

Classes I am registering for:
Aerobics
Walking
Stair Climbing
Line Dancing

Participating in exercises involves activities that use cardiovascular function, strength, balance, flexibility and end deep breathing – a potentially hazardous activity which may include risks such as, but not limited to, increase in heart rate, light headiness, falls, contact with other participants, sprains and strains


I represent and warrant that I am physically fit and able to participate in physical exercise.  I agree to stop and request assistance if I experience any symptoms such as, but not limited to, dizziness, excessive fatigue, chest pains, pains in my shoulder, arms, or hands, shortness of breath, or any other conditions which would make it difficult or unsafe to continue.  I acknowledge that my participation in this program is voluntary and that I can stop my participation in the class at any time.  I further acknowledge that I am participating in the class at my own risk.
I agree for myself, my heirs, executors and administrators, not to sue and to release , indemnity and hold harmless SUNY Downstate Medical Center, and its directors and instructors from any and all liability, claims, demands and causes of action whatsoever, arising out of my participation in this class.