Mercy Sports Medicine and Rehabilitation Center Mercy Acceleration – INFORMED CONSENT Date:____/____/____ 1. All programs are non-refundable and non-transferable and are designed to be completed in six to10 weeks to achieve optimal results. Training must be completed in 10 weeks or the remainder of account will be forfeited. Please talk to a trainer if you are approaching the expiration date and will not complete the remaining sessions. 2. If at any time I am unable to complete the Acceleration program due to an injury sustained during training at Mercy Acceleration or away from the program, the prorated balance of the training fee will be maintained on account until I am able to complete my training. 3. My participation is voluntary and I may withdraw from the evaluation or program at any time. Benefits associated with my participation include increased fitness, performance and knowledge regarding physiology and biomechanics of sports performance training. 4. Testing and training will be under the direction of Mercy Acceleration staff. 5. I hereby consent to and permit Mercy Acceleration staff to use the data obtained from the Acceleration program in reports or publications. My identity will not be associated with such reports unless I have given specific permission to do so. 6. In the event of physical injury resulting from evaluation procedures, equipment usage, or training, NO follow-up medical treatment or momentary compensation will be provided by MERCY HEALTH SYSTEM, MERCY SPORTS MEDICINE AND REHABILITATION CENTER, or MERCY ACCELERATION. I must look to my own health insurance policies. 7. I acknowledge that Mercy Acceleration staff is relying on all information provided by me regarding my medical history and condition before allowing me to participate in any evaluation or training. I certify the information provided to be true, correct and complete. 8. Training fees are to be paid in full before any training or testing. The health history and informed consent form must be completed before the first training session. 9. I will make every effort to be on time (five to 10 minutes early) for my scheduled appointments. Cancellations should be made one day in advance. If I fail to show for a scheduled training session or fail to notify Mercy Acceleration of an appointment change or cancellation at least four hours prior to the session, I will forfeit a paid session. If I am five to 15 minutes late for a scheduled appointment I will receive a modified training session to fit the time remaining in the session. If I am over 15 minutes late for an appointment, I will forfeit that session. Mercy Acceleration reserves the right to charge for any missed appointments. ________________________________________________ (Signature of participant) I acknowledge the participant is under the age of 18. I have reviewed the information above and agree to follow the guidelines set forth. I consent to ______________________ participating in the Mercy Acceleration program. (Print participant’s name)
_____________________________________________ (Parent or guardian’s signature)