PHYSICAL ACTIVITY READINESS CERTIFICATION
& RELEASE FORM
The undersigned hereby gives informed consent to engage/participate in a variety of physical activities. The
possibility exists that certain detrimental physiological changes may occur during physical activity/exercise.
These changes could include, but are not limited to, heat related illness, abnormal heart beats, abnormal blood
pressure, subluxation, strains, sprains, broken bones, and in rare instances, heart attack or death. I
understand that any activity involving motion and/or height creates the possibility of accidental injuries.
Physical activities should be undertaken only by properly trained and qualified participants under supervised
conditions. Participation without proper training and/or conditioning could be dangerous and should not be
undertaken. Before participation in any activity, know your own limitations, the limitations of your classmates
and the limitations of the equipment. I understand that I am not permitted to attempt any maneuver/skill which
has not been covered during class instruction without the instructor’s permission. If in doubt, always consult
your instructor.
I hereby acknowledge and certify that:
The instructor has informed me that he/she cannot be omnipresent and observe my every movement. I
understand that there are inherent risks associated with any physical activity and recognize it is my
responsibility to monitor my individual physical status during activity. I understand that the ultimate
responsibility for my safety is mine alone. I have been instructed in the safety guidelines of the program and
as a responsible adult, I hereby agree to abide by them and use good judgment in my class conduct.
I do not have any physical/mental limitations or conditions which would prohibit/impair my/others safety or
participation in this class. In the event of a medical problem, I recognize that any medical care that may be
required is my personal financial responsibility. After being appraised of the nature of the PROGRAM and with
full knowledge of the range of consequences, including adverse physical reactions that may happen to those
who participate in such programs, I hereby accept the risks associated with participation and agree to hold
harmless/release the Los Angeles Community College District, Los Angeles Mission College, it’s employees,
agents, coaches, representatives and volunteers from any and all liability (known & unknown), negligence,
actions, causes of action, debts, claims or demands of any kind and nature whatsoever, which may arise by or
in connections with my participation in this program.
By signing this form, I certify that I have read all of the foregoing, understand it, and agree to all of the
conditions of participation in the program for myself and/or son/daughter.
____________________________
Print Participant’s Name
______________________________
Participant’s Signature
_________________________
Date Signed
______________________________
Parent/Guardian Signature
(If under 18 yrs)
PHYSICAL ACTIVITY
INFORMED CONSENT RELEASE
Los Angeles Mission College
GENERAL RELEASE 9/9/14 tsm