ROCK VALLEY SPORTS PERFORMANCE Information. Participant s Name: Date:
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1 ` ROCK VALLEY SPORTS PERFORMANCE Information Participant s Name: : Total Price: $ Down Payment: $ Balance Due: $ Scheduled Payment Plan: $ Final payment is due by: The program is designed for three day a-week training for the predetermined length of time (ex. 6 weeks, 8 weeks, 12 weeks etc.), in order to achieve optimal results. If after below completion date, training is not completed, your remaining session will be forfeited. Sessions cannot be carried over for future training. If failure to complete training is due to injury or physician advice, arrangements to extend your training must be made and approved prior to 90 days. ***2 weeks free for returning athletes is non-refundable, any refunds provided, due to injury or physician advice will be pro-rated from normal package pricing. Cancellation should be made one day in advance. Failure to show for an appointment will lead to a forfeiture of that appointment. Over 15 minutes late will also lead to forfeiture of that appointment. Package Purchased: sessions, at days a weeks This training session will be completed no later than-completion : I agree to the payment plan and program length. Signed: : (Participant or Parent/Guardian) Witness: Please keep this PAYMENT AGREEMENT until your account is paid in full. Checks should be made payable to and mailed to: RVSP rd Ave Moline, IL 61265
2 Package # Cost Location IA IL I,, being 18 years of age or older, or with parent/guardian consent if under 18, and being fully informed as to the program activities of Rock Valley Sports Performance, am participating in the Rock Valley Sports Performance Program ("RVSP"), a Division of Rock Valley Physical Therapy, on my own accord. I acknowledge and represent that I have revealed my medical history to the program coordinator or his designee, including any past or current injuries, to the best of my knowledge. I understand that compliance with this training program is essential to achieve the maximum training result. Overtraining, by participating in other weight training programs at the same time, may be detrimental to my overall success and performance with the Rock Valley Sports Performance program. I understand that I will be actively participating in strenuous physical activities to enhance athletic performance as part of my strength and conditioning program with RVSP, and that I may be exposed to certain risk of incurring injuries. Potential risks include injuries from use of high-speed treadmill, the use of weighted medicine balls in multiple planes like flexion and rotation, weighted lifting activities, and jumping activities involving single or double legs and moving in multiple directions, etc. I understand that at any point I have the option to discontinue an activity if I feel I cannot perform it safely due to pain or discomfort or for any other reason, and that I shall notify the program supervisor immediately of my decision to discontinue such activity. I give my permission for this to be done. I do not give permission for this to be done. (Please initial one of the two options above) I acknowledge that I am responsible for payment of fees for these services and that there is no insurance reimbursement for these types of services. Participant (Printed Name) Parent or Guardian (if participant under age 18)
3 PARTICIPANT HISTORY INFORMATION I do not want to receive RVSP information/newsletters Package # Cost: PARTICIPANT Birth date Age (Full name, Please do not use initials) Married Single Widowed Male Female Soc. Sec.# Home Address City State Zip Code Home Phone School Grade level Sports Employer Occupation_ Business Address City State Zip Code Name of Spouse_ Soc. Sec. # DOB Spouse Employed by_ Business Phone Participant Referred by Emergency Contact Person Phone IF PARTICIPANT IS A MINOR, COMPLETE THIS SECTION FATHER: Name Soc. Sec. # DOB Employer Employer Phone MOTHER: Name_ Soc. Sec. # DOB Employer Employer Phone HOME ADDRESS OF PARENT(S) if different than participant's
4 Name School Parent s names_ of Birth Year in School Emergency contact Involved in what sports Do you have any history of injuries while participating in sports (past of present)? If YES please describe. Please list any surgeries undergone. Are you currently taking any medication or have any medical condition that requires an inhaler? What goals do you wish to accomplish by participating in this program? What are your personal goals for the upcoming season(s)?
5 Consent for Photography/Videotaping I hereby give my consent to have photographs, videotaped images, or other images made of myself or of someone for whom I am a legal representative. I consent to the use of these images for the purposes identified below, which may include use and disclosure outside of Rock Valley Physical Therapy. I understand that I may request a copy of this form. X Educational/Training Programs X X Promotional/Marketing Materials Public Media Medical Records Other Rock Valley Physical Therapy Center, its employees, and officers are hereby released from any legal responsibility or liability for disclosure of the images to the extent indicated and authorized herein. This authorization for photography remains valid until or unless the patient or legal representative withdraws or restricts the authorization. Printed name of person being photographed/videotaped _ Signature (Legal representative if other than self) _ Printed Name Relationship if other than self Witness
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