2009 PATHWAYS WOMEN'S HEALTH RELEASE FORM

ALL INDIVIDUALS WHO WISH TO PARTICIPATE IN THE WELLNESS PROGRAMS PRESENTED BY PATHWAYS WOMEN'S HEALTH ARE REQUIRED TO COMPLETE & RETURN THIS FORM PRIOR TO ADMISSION TO THE PROGRAMS.

I have been informed and understand that no one should start a wellness program without first obtaining medical clearance, especially if there is a personal or family history of heart disease, high blood pressure, or if you are pregnant, have diabetes, total cholesterol over 240, smoke cigarettes or are overweight.  I have been advised that it is my sole responsibility to be cleared by my own personal physician to be able to participate in the Wellness Program at Pathways Women's Health.  I am aware that Pathways will not provide medical clearance or evaluation for my ability to participate in any aspect of the WELLNESS PROGRAM.

I fully understand that should I injure myself in any manner as a result of my participation in Pathways Women's Health WELLNESS PROGRAM, I, __________________________________, hereby release, discharge, and hold harmless Pathways Women's Health from any liability now or in the future including, but not limited to, heart attack, muscle strain, pulls or tears, broken or fractured bones, shin splints, heat prostration, injuries to knee, hip, shoulder, neck, lower back, foot, and any other illness, soreness or injury however caused, occurring during or after my participation in the WELLNESS PROGRAM. 

In signing this release, I acknowledge that I have read and understand the above information and stipulations.  I hereby agree and will absolve and hold harmless Pathways Women's Health, Manhasset Diagnostic Imaging, Inc., its instructors, employees and owners from and against any blame and liability for injury, misadventure, harm loss, inconvenience or damage hereby suffered or sustained as a result of participation in any of the wellness/exercise programs offered.

Please indicate the initial class for which your are registering                                                                                                      

_______________________________                                             ____________________

Name (please print)                                                                              Date

_______________________________                                              ______________________

Signature                                                                                              Witness

__________________________________________                                                             ______________________________________________________

Address                                                                                                Daytime phone                       Evening phone _______________________________                                                                                                                                                         

   PHYSICIAN'S SECTION

Kindly complete and return to: Pathways Women's Health    1350 Northern Boulevard    Manhasset, NY 11030

Attn: Mollie Sugarman, Program Director *  Phone : (516) 365-9760

- or-Fax to: (516) 365-2078 or E-MAIL to: molsugarman@mdiradiology.com

 TO: PATHWAYS WOMEN'S HEALTH

____________________________  has been examined by me and is medically cleared to participate in any of the           

  (Name of your patient)                     physical programs at Pathways Women's Health.  My patient has been informed

                                                         of any limitations that may apply to his/her physical condition

RESTRICTIONS/LIMITATIONS: ____________________________________________________________________________                                                                

__________________________________________      _________________________     _________          

NAME OF PHYSICIAN (please print)                              PHYSICIAN'S SIGANATURE &  DATE

PHYSICIAN'S STAMP MUST APPEAR

BELOW:                                                                           (_______)______________________ 

       phone                                                     

      _______________________________       street address

                                                                          

      _________________________________                       

        City/State/Zip

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