MWCS FITNESS CENTER
MEDICAL RELEASE FORM
I have completed the Physical Activity Readiness Questionnaire (PAR-Q) on the back of this sheet. I have answered YES to at least one of the questions. I am required written permission from you to use any of the following equipment at the MWCS Fitness Center.
NAME ___________________________
Machine |
Approved |
Disapproved |
Limitations |
|
Treadmill |
|
|
|
|
Elliptical (cross trainer) |
|
|
|
|
Stationary Bike (recumbent & upright) |
|
|
|
Machine |
Approved |
Disapproved |
Limitations |
|
Leg Press (quads, hams, glutes) |
|
|
|
|
Leg Extension (quadriceps) |
|
|
|
|
Leg Curl (hamstrings) |
|
|
|
|
Chest Press (pectoralis group) |
|
|
|
|
Rear Deltoid/Pec Fly (deltoids & pecs.) |
|
|
|
|
Lat Pulldown/Low Row (latissimus dorsi) |
|
|
|
Muscles/ Exercise
|
Approved |
Disapproved |
Limitations |
|
Biceps & Triceps |
|
|
|
|
Obliques |
|
|
|
|
Chin Ups & Dips |
|
|
|
|
Squats & Calf Raises |
|
|
|
|
Military & Chest Press |
|
|
|
|
Abdominals |
|
|
|
|
Back Extensions |
|
|
|
Physician Signature:
_________________________
Date: _______________