Physical Activity and Exercise Program Indemnity Form

Physical Activity and Exercise Program Indemnity Form


Membership: Are you a current member of the Harrow Bush Nursing Centre?
If no, a staff member from the Centre will contact you to discuss the benefits of membership. Please note non-member fees apply to activities at HBNC and HNH.




Do you have current Ambulance Cover?

Pre-Exercise Screening

This pre-exercise screening does not provide advice on a particular matter, nor does is substitute for advice from an appropriately qualified medical professional. No warranty of safety should result from its use. The screening system in no way guarantees against injury or death. No responsibility or liability whatsoever can be accepted by the Harrow Bush Nursing Centre (HBNC) or the auspiced body Harrow Neighbourhood House for any loss, damage or injury that may arise from any person acting on any statement or information contained in this tool. AIM: to identify those individuals with a known disease, signs or symptoms of disease, who may be at a higher risk of an adverse event during physical activity/exercise. This stage is self-administered and self-evaluated.

1. Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?
2. Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?
3. Do you ever feel faint or have spells if dizziness during physical activity/exercise that causes you to lose balance?
4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?
5. If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months?
6. Have you had any falls in the past 12 months:
7. Are you pregnant?
8. Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?
9. Do you have any other medical condition(s) that may affect or harm you in your participation in physical activity/exercise?
10. Do you have any other muscular or skeletal injuries or physical condition(s) that may affect or harm you in your participation in physical activity/exercise?

IF YOU ANSWERED ‘YES’ to any of the 7 questions, you may be requested by the Fitness Instructor to seek guidance/clearance from your GP or appropriate allied health professional prior to undertaking physical activity/exercise.

IF YOU ANSWERED ‘NO’ to all of the 7 questions, and you have no other concerns about your health, you may proceed to undertake light-moderate intensity physical activity/exercise once this form is approved.

Participant Physical Activity and Exercise Program Guidelines.

Classes and workshops are open to any medically fit person who is able to participate at their own level of exercise activity.
If you are in any doubt about your medical fitness or have a medical condition, it is your responsibility to obtain a Doctors medical clearance prior to attending the exercise program.
Participants are required to make the program instructor aware of any medical conditions and complete the Medical Information and Pre Exercise Screening Section on page 2 and 3 and if required, provide a medical clearance certificate.
Please ensure you make the instructor aware if your health, medical or physical conditions change at any time during the year.
Participants must work within their own capacity/comfort zone at all times and rest if needed.
Participants are to respect fellow class participants and should report any adverse development that could affect their own safety or the safety of others.

Participant acknowledgement and confirmation.

  • I have read the Participant Physical Activity and Exercise Program Guidelines above and understand that there is an inherent risk in any physical activity or exercise.
  • I agree to abide by the rules set out in the Participant Physical Activity and Exercise Program Guidelines above
  • I believe to the best of my knowledge, all the information I have supplied within the above pre-exercise screening section is correct.
  • I agree to obtain guidance or clearance from my GP or appropriate allied health professional, if required, prior to my commencement in the activities
  • I consent to my de-identified information being shared with the Primary Health Network (PHN) for the purposes of improving our services
  • I agree to release Harrow Bush Nursing Centre and its instructors from any liability in the event of any injury I may sustain as a result of my participation in class.

Approval for the participant to proceed with physical activity or exercise

I acknowledge the participant can partake in the following physical activity or exercise programs:

I agree to those checked activities (below).