Membership Registration formStep 1 of 714% Please noteThis form is only for students who are 18 years of age and older. If you are under-aged, please visit the MAC for the paper version of the forms in order to gather the necessary parental consent signatures.I am:*a studentfacultystaffStudent informationName*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Enter Email Confirm Email Main phone*Cell phone*Gender*Age*Date of birth*Height*Weight*Emergency contactEmergency contact person*Relationship*Telephone number*Additional InformationHealth questionnaireRegular physical activity is fun and healthy, and safe for most people.However, some individuals may have health-related risks that might require them to check with their physicians prior to starting an exercise program.To help determine if there is a need for you to see your physician before starting an exercise program, please read the following questions and answer carefully.All information will be kept in the strictest confidentiality.I. Physical activity screening questions. Please choose "Yes" or "No".*YesNoHas your physician ever told you that you have a heart condition?Do you experience pain in your chest when you are physically active?In the past month, have you experienced chest pain when not performing physical activity?Do you lose balance because of dizziness or do you ever lose consciousness?Do you have a bone or joint problem that could be aggravated by a change in your level of physical activity?Is your physician currently prescribing medication for your blood pressure or heart condition?Do you know of any other reason why you should not participate in a program of physical activity?If you answered "yes" to any of the above questions, it is recommended that you consult with your physician via phone or in person before participating in a physical activity program.II. General health history questions. Please choose "Yes" or "No".*YesNoHave you ever experienced a stroke?Do you have diabetes?Do you have asthma or another respiratory condition that causes difficulty with breathing?Do you have orthopedic conditions that would restrict you in performing physical activity?Have you ever been told by a physician that you have high blood pressure?Have you ever been told by a physician that you have elevated blood lipids(cholesterol)Do you currently smoke?Have you experienced within the past 6 months back pain or discomfort that prevented you from carrying out normal daily activities?Are you pregnant? Do you currently exercise less than one hour per week?Are you currently taking any medications that might impact your ability to safely perform physical activity?By submitting this form I understand that I am voluntarily participating in an athletic or physical activity at The MAC with full knowledge and understanding and appreciation of the risk of injury inherent in any physical exercise, massage or therapy program, physical activity, or athletic activity and expressly assume all risk of injury and even death, which could occur by reason of my participation. I release The MAC from any liability and agree not to sue the MAC with respect to any cause of action for bodily injury, property damage, or death occurring to me as a result of my participation in the activity.I understand that all personal property brought to the MAC is brought at my sole risk as its theft, damage, or loss.Please click below to acknowledge and agree with the terms of the Activity release agreement for adults.I understand and agreeHealth historyRegular physical activity is safe for most people. However, some individuals should check with their doctor before they start an exercise program.To help us determine if you should consult with your doctor before starting to exercise with ( your organization), please read the following questions carefully and answer each one honestly. All information will be kept confidential.Please check "Yes" or "No".*YesNoDo you have a heart condition?Have you ever experienced a stroke?Do you have epilepsy?Are you pregnant?Do you have diabetes?Do you have emphysema?Do you feel pain in your chest when you engage in physical activity?Do you have chronic bronchitis?In the past month, have you had chest pain when you were not doing physical activity?Do you ever lose consciousness or do you ever lose control of your balance due to chronic dizziness?Are you currently being treated for a bone or joint problem that restricts you from engaging in physical activity?Has a physician ever told you or are you aware that you have high blood pressure?Has anyone in your immediate family(parent/brother/sister) had a heart attack, stroke or cardiovascular disease before age 55?Has a physician ever told you or are you aware that you have high cholesterol level?Do you currently smoke?Are you a male over 44 years of age?Are you a female over 54 years of age?Are you currently exercising LESS than 1 hour per week? If you answered no, Please list you activities.Are you currently taking any medication?If you answered "No" to whether or not you are currently exercising LESS that 1 hour per week, please list your activities.If you are currently taking medication, please list the medications and their purpose.What are your specific fitness goals at the MAC? (Indicate all that apply)* Increase strength and endurance Improve cardiovascular fitness Reduce body fat Exercise regularly Sports conditioning Improve flexibility Improve muscle tone Increase muscle mass Injury rehabilitation OtherIf other, please specify:*What are your specific health goals at the MAC? (Indicate all that apply)* Reduce stress Control blood pressure Stop smoking Improve productivity Feel better overall Improve nutritional habits Control cholesterol Achieve balance in life Reduce back pain Increase my health awareness OtherIf other, please specify:*What motivated you to join the MAC? (Indicate all that apply)* Convenience / location Peer support Medical reasons OtherIf other, please specify:*I have read, understood, and completed this health history questionnaire. I made sure to seek out answers to any questionsto my full satisfaction.By checking this box, I am acknowledging that I have read and understood the statement listed above.* I agree and understand.Health/fitness pre-participation screening questionnaire for studentsAssess your health needs by marking all TRUE statements.History - you have had: Heart attack Heart surgery Cardiac catherization Pacemaker/ implantable cardiac defibrillator/ rhythm disturbance Heart valve disease Heart failure Heart transplantation Congenial heart diseaseIf you marked any of the statements in this section, consult your healthcare provider before engaging in exercise. You may need to use a facility with a medically qualified staff.Symptoms - you have had: You experience chest discomfort with exertion You experience unreasonable breathlessness You experience dizziness, fainting, blackouts. You take heart medications.Other health issues: You have musculoskeletal problems. You have concerns about the safety of exercise. You take prescription medication(s). You are pregnant.Cardiovascular risk factors: You smoke. Your blood pressure is greater than 140/90. You don't know your blood pressure. You take blood pressure medication. Your cholesterol is >240 mg/dL. You don't know your cholesterol level. You are diabetic or take medicine to control your blood sugar. You are physically inactive (ex. you get less than 30 minutes of physical activity on at least 3 days per wk) You are more than 20 pounds overweight.If you marked two or more of the statements from the "Symptoms", "Other health issues", and "Cardiovascular risk factors" sections, you should consult your healthcare provider before engaging in exercise. You might benefit from using a facility with a professionally qualified exercise staff to guide your exercise program.If none of the above is true for you, you should be able to exercise safely without consulting your healthcare provider in almost any facility that meets your exercise needs.Mulerider Activity CenterPlease check if you have a history of the following: Heart attack Heart surgery Cardiac catheterization Coronary angioplasty (PTCA) Pacemaker/ implantable cardiac defibrillator/ rhythm disturbance Heart valve disease Congestive heart failure Heart transplantation Congenital heart diseaseDate of the attack:*Heart surgery: CABx:*Stent #:*Please check if you have any of the following symptoms: Experience chest discomfort with exertion Experience unreasonable breathlessnessPlease mark ALL true statements. You are a man older than 45 years. You are a woman older than 55 years or you have had a hysterectomy or you are post- menopausal. You smoke. Your blood pressure is greater than 140/90 mmHg. You take blood pressure medication. Your blood cholesterol is greater than 240/mg/dL You have a close blood relative who had a heart attack before age 55(father or brother) or age 65 (mother or sister) You are diabetic or take medicine to control your blood sugar. You have been diagnosed with kidney disease. You have pulmonary (lung) problems. You have been diagnosed with thyroid or other endocronological disorder. You have respiratory problems, such as asthma, chronic bronchitis, emphysema or COPD. You have muscular problems. You have arthritis, rheumatism, or gout. You have other orthopedic problems. You are pregnant. You have Multiple Sclerosis. You have been diagnosed with osteoporosis. You are 20 lbs. or more overweight.What is the name of your blood pressure medication?Which relative had the heart attack, and at what age?What medicine do you take to control your blood sugar?What are your O2 requirements for your lung problems?Do you have any other medical conditions we need to be aware of?Please list any previous surgeries you have undergone, and their dates.List any medications you are taking, the dosage, and their usage.Release and Healthcare VerificationI, the undersigned, agree to indemnify and hold harmless, Southern Arkansas University, and employees from any claims, damages and actions of any kind or nature, whether at law or in equity, arising from my participation in the Southern Arkansas University Mulerider Activity Center, provided that such liability is not attributable to the sole negligence of the University.I realize that my participation in this activity involves risk of injury, including but not limited to tendonitis, strains, sprains, bursitis, fractures, delayed muscle soreness, contusions, abrasions, serious eye damage and even the possibility of death. Also, I recognize that there are many other risks of injury including serious and disabling injuries which may arise due to my participation in this activity and that it is not possible to specifically list each and every individual injury risk. By signing this form I desire, consent and voluntarily choose to take part in all such activities. Knowing the material risks and appreciating, knowing and reasonably anticipating that other injuries and death is a possibility, I assume all the risks normally incident to the nature of the activities and agree that the University or any of its employees conducting such activities will not be responsible for any damages or injuries resulting to me.Furthermore, I also confirm that I have appropriate healthcare insurance for this activity or if not, that I will not rely upon the University for medical expenses. Also, I understand that any injury incurred and the resulting medical expense from that injury will be my responsibility and the University will not be responsible for any related expenses.I acknowledge the release and healthcare verification listed above, and understand that by submitting the form I am agreeing to its terms.* I understand and agreeI hereby give express written permission for my photograph to be used in the advertising and promotion of Southern Arkansas University, Magnolia, Arkansas. This includes printed as well as electronic publications (web pages).I understand and agree to the terms of the photo release.* YesAgreement and Release of Liability FormIn consideration of gaining membership or being allowed to participate in the activities and programs of the Mulerider Activity Center and to use its facilities, equipment, and machinery, I do hereby waive, release and forever discharge Southern Arkansas University and it officers, agents, employee, representatives, executors, and all other persons from any and all responsibilities or liability for injuries or damages resulting from my participation in all activities or my use of equipment or machinery in the above-mentioned facilities or arising out of my participation in any activities at said facility. I do also hereby release all of those mentioned and any others acting upon their behalf from any responsibility or liability for any injury or damage to myself, including those caused by the negligent act or omission of any of those mentioned or others acting on their behalf or in any way arising out of or connected with my participation in any activities of the Mulerider Activity Center or the use of any equipment at the Mulerider Activity Center.I understand and am aware that strength, feasibility, and aerobic exercise, including the use of equipment, is a potentially hazardous activity. I also understand that fitness activities involve a risk of injury and even death and I am voluntarily participating in these activities in these activities and using equipment and machinery with knowledge of the dangers involved. I hereby agree to expressly assume and accept any and all risks of injury or death.I do hereby further declare myself to by physically sound and suffering from no condition, impairment, disease, infirmity, or other illness that would prevent my participation in any of the activities and programs of the Mulerider Activity Center or use of equipment or machinery except as hereinafter stated. I do hereby acknowledge that I have been informed of the need for a physician’s approval for my participation in an exercise/fitness activity or in the use of exercise equipment and machinery. I also acknowledge that it has been recommended that I have a yearly or more frequent physical examination and consultation with the physician as to physical activity, exercise, and use of exercise and training equipment so that I might have recommendations concerning these fitness activities and equipment use. I acknowledge that I have either had a physical examination and have been given a physician’s permission to participate, or that I have decided to participate in activity and/or use of equipment and machinery without the approval of my physician and do hereby assume all responsibility for my participation and activities, and utilization of equipment and machinery in my activities.By submitting this form I am agreeing to the terms outlined in the "Agreement and Release of Liability Form", as well as all the other releases and signatures submitted throughout the form.* I understand and agree.
