KSL Waiver & Pre-testing Guidelines

ATHLETE NAME:
Kinesic Sport Lab Limited
6331 Lady Hammond Road, Suite 102
Halifax, NS B3K 2S2
Phone: 1.902.406.9931
E-mail: [email protected]
PRE-TESTING LETTER
Dear Athlete,
Please review this pre-testing information package regarding your exercise physiology assessment.
Day of Testing: Prior to testing, preliminary blood pressure and heart rate values will be assessed. You will be
required to submit a completed Athlete Information Form, Informed Consent, Waiver and Health
Clearance (PAR-Q) Form, which is signed and dated.
FOR OPTIMAL RESULTS, PLEASE FOLLOW THE PRE-TEST GUIDELINES:
• No alcohol consumption within 24 hours prior to testing.
• No strenuous exercise within 6 hours prior to testing
• No smoking within 4 hours prior to testing
• Refrain from drinking caffeinated beverages within 2 hours prior to testing
• Drink 2 to 4 glasses of water 2 hours prior to measurements
Running/Strength & Conditioning tests
• Indoor running shoes
• Socks
• Shorts
• T-shirt
Cycling tests
• Bike (clean please – dirt & salt are rough on our testing equipment)
• Smooth back tire
• Cycling shorts
• Shirt
• Cycling shoes and socks
General items
• Water bottle
• Snack for after your test
• Small towel
• Heart rate monitor (if you have one, otherwise we’ve got you covered)
Under rare circumstances, where additional medical documentation is required for exercise
clearance, you will not be permitted to participate in testing on that day.
Please contact us if you have any questions or concerns regarding your upcoming testing session or program series,
Team KSL
ATHLETE NAME:
Kinesic Sport Lab Limited
6331 Lady Hammond Road, Suite 102
Halifax, NS B3K 2S2
Phone: 1.902.406.9931
E-mail: [email protected]
ATHLETE INFORMATION
NAME: __________________________________________________________________________________
EMERGENCY CONTACT NAME & RELATION: _______________________________________
EMERGENCY CONTACT PHONE NUMBER(S): _______________________________________
BIRTHDAY (month/day/year): _________________________________________________________
ALLERGIES/HEALTH CONCERNS/EMERGENCY MEDICATIONS: ______________________
__________________________________________________________________________________________
PHONE NUMBER(S): ___________________________________________________________________
MAILING ADDRESS: ____________________________________________________________________
__________________________________________________________________________________________
E-MAIL ADDRESS: ______________________________________________________________________
KSL PROGRAM(S)/SERVICE: ___________________________________________________________
ATHLETE NAME:
Kinesic Sport Lab Limited
6331 Lady Hammond Road, Suite 102
Halifax, NS B3K 2S2
Phone: 1.902.406.9931
E-mail: [email protected]
INFORMED CONSENT
This consent form is only part of the process of informed consent. It should give you the basic idea of what the course laboratory
physiological testing is about and what your participation will involve. If you would like more detail about something mentioned here,
or information not included here, please ask. Take the time to read this carefully and to understand any accompanying information.
In order to evaluate and monitor physiological function(s), the following laboratory or field test(s) may be
conducted:
Athlete /
Guardian Initials
KSL Initials
Description of Assessment
Anthropometric measurements: Standing height, weight, waist and hip
circumferences and body composition may be assessed.
Muscular strength, endurance, mobility, and power: Push-ups, vertical jump, grip
strength, pull-ups, squats, balance, sprinting, running, cycling, etc.
Lactate threshold testing: An incremental lactate test will be completed on a treadmill
or cycle ergometer. Lactate will be measure by finger prick blood sample.
Your physiological data will be compiled into a computer database to generate and track your physiological profile over the course
of time. Access to the database is strictly controlled and only the Director of Kinesic Sport Lab Limited will have access to the
information which may be released to you and to your coach upon written agreement. All results are kept in the strictest
confidence.
There have been few, if any, complications for those participating in the above physiological testing. If you are not tolerating the
stress, the activity will be stopped immediately. Mild light-headedness and muscle soreness may occur, but should disappear quickly.
Risk of injury is possible in all physical activity, but is minimal. Any injuries or feeling of discomfort should be reported to the test
administrator immediately. You are free to terminate the test at any time. In the event that you suffer injury as a result of
participating in the above physiological testing, Kinesic Sport Lab Limited will not be responsible for providing compensation to you.
You still have all your legal rights. Nothing said in this consent form alters your right to seek damages. The technician administering
these tests is trained in emergency procedures, and has appropriate qualifications to be conducting the tests.
Your signature on this form indicates that you have understood to your satisfaction the information regarding your participation in
the physiological testing and agree to participate as a subject. In no way does this waive your legal rights nor release Kinesic Sport
Lab Limited from their legal and professional responsibilities. You are free to withdraw from the testing at any time without
jeopardizing your health care. If you have further questions concerning matters related to this testing, please contact the Director at
902-406-9931.
Athlete Name: __________________________ Athlete Signature: ___________________________ Date: ____________
If applicable,
Guardian Name: ____________________________ Guardian Signature: ___________________________ Date: ___________
Witness Name: _________________________ Witness Signature: ___________________________ Date: ____________
KSL Name: _____________________________ KSL Signature: _______________________________ Date: ____________
ATHLETE NAME:
Kinesic Sport Lab Limited
6331 Lady Hammond Road, Suite 102
Halifax, NS B3K 2S2
Phone: 1.902.406.9931
E-mail: [email protected]
WAIVER
RELEASE OF LIABILITY, WAIVER OR CLAIMS, ASSUMPTION OF RISKS AND INDEMNITY AGREEMENT
IN SIGNING THIS DOCUMENT YOU WILL WAIVE CERTAIN LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE
PLEASE READ CAREFULLY
To: Kinesic Sport Lab Limited,
I _________________________________ acknowledge that participation in a fitness testing or training program has many inherent risks,
dangers and hazards and that while I am participating in a fitness testing/training program, I am exposed to and have full knowledge of the nature
and extent of such risks, dangers and hazards, which include but are not limited to abnormal blood pressure; fainting; disorders of heart rhythm;
heart attack; stroke or other cerebrovascular incident or occurrence; mental, physiological, motor, visual or hearing injuries, difficulties, deficiencies
of disturbances; partial or total paralysis; slips, falls or other unintended loss of balance or body movement related to walking which may cause
muscular, neurological, orthopedic, or other bodily injury; and other circumstances which could cause bodily injury, impairment, disability or death.
I FREELY ACCEPT AND FULLY ASSUME ALL SUCH RISKS, DANGERS AND HAZARDS AND THE POSSIBILITY OF
PERSONAL INJURY, DEATH, PROPERTY DAMAGE AND LOSS RESULTING THEREFROM.
RELEASE OF LIABILITY, WAIVER OF CLAIMS AND IDEMNITY AGREEMENT
In consideration of approval to participate in the fitness testing/training program, I agree as follows:
1.
TO WAIVE ANY AND ALL CLAIMS that I have or may in the future have against Kinesic Sport Lab Limited, its directors, officers,
employees, agents, representatives, successors and assigns (hereinafter collectively referred to as “THE RELEASEES”), and TO RELEASE
THE RELEASEES from any and all liability for any losses, damages, expenses and claims arising out of or in connection with injury jointly
and severally, of and (including death) or damage to property that I may suffer, or that my next of kin may suffer as a result of my participation
in the fitness testing program due to any cause whatsoever INCLUDING NEGLIGENCE, BREACH OF CONTRACT, OR
BREACH OF ANY STATUTORY OR OTHER DUTY OF CARE.
2.
TO HOLD HARMLESS AND INDEMNIFY THE RELEASEES from any and all liability for any loss, expenses, damages, demands
and claims arising out of or in connection with injuries (including death) or damages to any and all persons and to any and all property, in any
way sustained or alleged to have been sustained as a result of activities in which I engage which are beyond the scope of those activities
approved by Kinesic Sport Lab Limited.
3.
This agreement shall be effective and binding upon my heirs, next of kin, executors, administrators and representatives, in the event of my
death or incapacity. This Agreement shall be governed by and interpreted solely in accordance with the laws of _____________ (province of
residence).
I HAVE READ AND UNDERSTAND THIS AGREEMENT AND I AM AWARE THAT BY SIGNING THIS AGREEMENT I
AM WAIVING CERTAIN LEGAL RIGHTS WHICH I OR MY HEIRS, NEXT OF KIN, EXECUTORS, ADMINISTRATORS
AND REPRESENTATIVES MAY HAVE AGAINST THE RELEASEES.
Signed
at
_______________________,
(City/Town)
in
the
Province
of
_________________
(Province)
on
______
(Day)
/
______
(Month)
/ ______.
(Year)
Athlete Name: __________________________ Athlete Signature: ___________________________ Date: ____________
If applicable,
Guardian Name: ____________________________ Guardian Signature: ___________________________ Date: ____________
Witness Name: _________________________ Witness Signature: ___________________________ Date: ____________
KSL Name: _____________________________ KSL Signature: _______________________________ Date: ____________
ATHLETE NAME:
Kinesic Sport Lab Limited
6331 Lady Hammond Road, Suite 102
Halifax, NS B3K 2S2
Phone: 1.902.406.9931
E-mail: [email protected]
CREDIT CARD CHARGE AGREEMENT
BILLING COMPANY INFORMATION
Kinesic Sport Lab Limited
Suite 102 - 6331 Lady Hammond Road
Halifax, Nova Scotia B3K 2S2
PAYMENT GATEWAY
Mindbody Inc. & Optimal Payments
SERVICE/PRODUCT
__________________________________________________________________________________________
Payment Amount: $______________________ base fee $___________________________ including HST
Payment Frequency: _____ monthly
_____ one time
_____ other:
CREDIT CARD INFORMATION
Name on Card: __________________________________________________________________________
Card Number: __________________________________________________________________________
Expiry Date (mm/yy): _________________________________ Security #: ______________________
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