Name *

First Name

Last Name

Telephone Number *

(###)

###

####

Scheduled test date (if known)

MM

DD

YYYY

Testing method *

Treadmill

Bike

Are you comfortable on a treadmill? *

Yes

No

Do you use a treadmill in your training? *

Yes

No

Do you use a power meter? *

Yes

No

You will perform a MAXIMAL effort exercise test on a bike, a bike ergometer or a motor driven treadmill. The work levels will gradually increase throughout the test. The test can be stopped at any time should you experience fatigue, shortness of breath, dizziness, chest pain or any feelings of discomfort. There is risk involved with performing a maximal exercise test. Certain changes can occur in response to exercise including abnormal blood pressure changes, dizziness, myocardial infarction, stroke, or death. Every effort will be made to minimize these risks and emergency equipment and trained personnel will be available. Information you have about your health status or previous experiences with higher intensity physical effort or testing may affect the safety of your exercise test. You are responsible for fully disclosing such information to the staff. I have asked the test administer any questions I have pertaining to this maximal test and I understand that performance of this exercise test is completely VOLUNTARY and I am able to stop the test at any point. I hereby attest that I am in good health and my physical condition HAS BEEN VERIFIED by a licensed medical doctor, who has RELEASED ME to participate in strenuous physical activity and testing. I understand that an EKG test will NOT be conducted and there will NOT be a physician on site during my test. I have provided, in writing, a signed consent form from my physician stating that he/she is aware that I am performing a maximal exercise test, that there will be no physician present, that there is no contraindication to intense exercise, and that there will not be EKG monitoring during this test. *

I have read and I understand the test procedures that I will perform and the associated risks and discomforts. By checking this box and providing my name below, I consent to participate in the testing and do not hold eNRG Performance or the test administrator liable for any negative consequences that could arise from the test.

I hereby acknowledge that I have voluntarily chosen to participate in the VO2max testing through eNRG Performance. I am aware that eNRG Performance staff are not medical doctors and are not qualified to determine a participant’s physical capability to engage in strenuous exercise. The information given on the medical history questionnaire is correct to the best of my knowledge. I understand that absence of the physical problems listed on this form does not necessarily guarantee that I am in satisfactory health to participate in a VO2max test. ACKNOWLEDGEMENT OF RISK: I understand and acknowledge the risks involved in participating in VO2max testing with eNRG Performance, including, but not limited to, the risks involved in utilizing equipment or participating in any exercise or fitness activity. I have been informed that these risks, though remote, include abnormal blood pressure, fainting, disorders of heart rhythm, stroke, and very rare instances of heart attack or even death. I have been assured that every effort will be made to minimize these occurrences by precautions taken during testing. I have also been informed that emergency equipment and trained personnel are available to deal with these unusual situations should they occur. I understand that eNRG Performance does not employ doctors or EMTs. ASSUMPTION OF RISK: I understand that I am responsible for researching and evaluating the risks that I may face and am responsible for my actions. I also understand that if I have any doubts of my physical or mental condition, I am responsible for discussing the activities and risks involved in the VO2max test with my physician. Any activities that I may take part in, whether as a component of the VO2max test or separate from it, will be considered to have been undertaken with my approval and understanding of any and all risks involved. I agree to expressly assume and accept any and all risks associated with the VO2max test, including but not limited to, travel to/from the testing facility and limited availability of medical aid. By voluntarily participating in VO2max testing with the knowledge of the risks involved, I hereby agree to accept any and all inherent risks of property damage, bodily injury or death. RELEASE, INDEMNIFICATION, AND HOLD HARMLESS: In consideration for being allowed to participate in VO2max testing offered by eNRG Performance and to the fullest extent permitted by law, I agree to indemnify, defend and hold harmless eNRG Performance, its officers, owners, employees, consultants, volunteers, agents and assigns from and against all claims arising out of or resulting from my participation in the VO2max test, except for claims arising out of the sole negligence or willful misconduct of eNRG Performance, its officers, owners, employees, consultants, volunteers, agents and assigns. “Claim” as used in this agreement means any financial loss, claim, suit, action, damage or expense, including but not limited to attorney’s fees, attributable to bodily injury, sickness, disease or death, or injury to or destruction of tangible property including resulting loss of use. In addition, I hereby voluntarily release, forever discharge and agree not to sue eNRG Performance, its officers, owners, employees, consultants, volunteers, agents and assigns from any and all claims, both present and future, that may be made by me, my family, estate, heirs or assigns. I further understand that this acknowledgment of risk and hold harmless is intended to be as broad and inclusive as permitted by the laws of the State of Colorado, or any other applicable laws, and that if any portion hereof is held invalid, I agree that the remainder shall, notwithstanding, continue in full legal force and effect. I have read and fully understand this acknowledgement of risk and hold harmless agreement. *

I have read and agree to all of the information in the acknowledgement of risk and hold harmless agreement.

Date *

MM

DD

YYYY