HEART Program Participant Application and Release Form

Date of Birth*

Name*

First Name

Initial

Last Name

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone*

Email*

Race*

American Indian/Alaska Native Asian Black/African American Native Hawaiian/Pacific Islander White/Caucasian

Other:

Ethnicity*

Hispanic Non Hispanic

Emergency Contact*

Relationship*

Emergency Contact Phone*

By completing this form, I am agreeing to participate in the HEART program. I have been instructed to talk with my doctor about whether I can safely be a participant in exercises described in this program, and whether there are safety measures or limitations to my participation. I understand and agree there are risks, predictable and unpredictable, related with any program including exercise. I am aware of these risks and agree that my participation is at my own risk.

I hereby agree that neither the HealthVisions Midwest, nor the facility hosting the class, nor sponsoring organizations, nor their, officers, directors, employees, agents, members, or volunteers shall accept or have any responsibility or liability for expenses or medical treatment or for compensation for any injury I may suffer during or resulting from my participation in the HEART Program. I further agree not to sue any of the previous parties with respect to same. I do hereby, for myself, my heirs, executors, and administrators, waive, release, and forever discharge any and all rights and claims for damages that I may have or that may from this time accrue to me happening out of or in any way connected with my participation in this or any future programs.

I further understand and agree that my name, address, attendance record of this program is released to HealthVisions Midwest and sponsors for the purpose of data or program participation.

Having been fully informed of the circumstances in connection with the request for information from my record I hereby AUTHORIZE. To release to and/or obtain information from my Medical Providers. This information will be used for the HEART Program and AstraZeneca HealthCare Foundation.

I understand my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). If may also include information about behavioral or mental health services and treatment for alcohol and drug abuse.

I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing. I understand that the revocation will not apply to information already released in response to this authorization. Unless otherwise revoked, this authorization will expire in two years.

I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I understand that I may inspect or copy the information to be used or disclosed. I understand information disclosed pursuant to this authorization may be re-disclosed by the recipient and no longer protected by federal privacy regulations.

I consent to being photographed and authorize the use and reproduction of all proofs, original or copies, for whatever purpose, without further compensation to me and I understand this information may be shared with the Poor Handmaids of Jesus Christ.

By clicking the box and typing my name and date below, I am stating that I have read, understand, and agree to this information.

Electronic signature*

Please type your full name.