BRAIN POWER HOUR (BPH) SASKATOON BPH REGISTRATION Name * First Name Last Name Phone (###) ### #### Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Age * Emergency Contact Name * First Name Last Name Emergency Contact Phone * (###) ### #### Emergency Contact Relationship * Do you have a seizure disorder? Check yes or no. Yes No In the event that you have a seizure during walking group, please inform us of your seizure protocol below: Please list any behaviours that could put yourself or others at risk during participation in BPH Walking group: Numerous health benefits may result from the participation of regular physical exercise, however, any change in physical activity levels may increase your risk of injury. Complete this questionnaire before participating in the SBIA’s exercise or walking program. Below are a series of questions. Please read each question carefully and answer honestly by checking the box if your answer is YES to that question. 1. Has a physician ever told you that you have a heart condition and that you should only do physical activity recommended by a physician? 2. Has a physician ever told you that you have high blood pressure? 3. When you do physical activity do you feel pain in your chest? 4. In the last month, have you felt pain in your chest while at rest or during your activities of daily living? 5. Do you ever loose consciousness, or do you ever lose your balance because of dizziness? 6. Do you have any joint or bone problems that may be made worse by a change in your physical activity? 7. Have you been diagnosed for osteoporosis or had any bone fractures? 8. Do you have any lung or breathing problems? 9. Do you have insulin dependant diabetes? 10. Do you know of any other reason why you should not exercise or increase activity? If you answered YES to any of the questions, or if you are concerned about your health by participating in this program, we recommend talking to your doctor BEFORE participating. Tell your doctor about your intent to participate in this program and to which questions you answered ‘yes’ to. If you DIDN'T answer yes to any of the questions, then you are able to safely engage in the BPH program. In Case of Ambulation: Uses no mobility aids and can ambulate without difficulties Ambulates with difficulty (no aids) Ambulates with aids (cane, walker) Uses a wheelchair independently Uses a wheelchair and is unable to use independently Please list any other special needs, allergies, etc PROGRAM WAIVER In Consideration of the acceptance of my application to participate in the SBIA Brain Power Hour program in 2024 & 2025, for myself, my heirs, executors, administrators, successors and assigns HEREBY RELEASE, WAIVE AND FOREVER DISCHARGE, the Saskatchewan Brain Injury Association, and all other associations sanctioning bodies and sponsoring companies and all their respective agents, officials, successors and assigns OF ALL AND FROM ALL claims, demands, damages, costs, expenses, actions and cases of action, whether in law or equity, in respect of death, injury, loss or damage to my person or property HOW SO EVER CAUSED, arising or to arise by reason of my participation in the said event, whether as a spectator, participant, or otherwise: whether prior to, during or subsequent to the event AND NOTWITHSTANDING that same may have been contributed to or occasioned by the negligence of any of the aforesaid. I FURTHER HEREBY UNDERTAKE HOLD, SAVE HARMLESS and AGREE TO INDEMNIFY all of the aforesaid from and against any and all liability incurred by any or all of them arising as a result of, or in any way connected with my participation in the said event. I attest and verify that I am fully aware of the physical risk of injury or death in participating in this event and voluntarily agree to accept full responsibility and legal liability for same, that I am physically fit and sufficiently trained for this event. I am also aware that the weather conditions in 2024 & 2025 may be unpredictable thus posing an increased physical risk. By submitting this entry, I acknowledge having read and agreed to the above waiver, release, indemnification and attestation. I hereby authorize Saskatchewan Brain Injury Association to release and to publish, in print or non-print form, any photographs, videos or recordings taken of my children and/or myself. Todays Date * MM DD YYYY Name of person submitting this registration form. * First Name Last Name Thank you! We have received your registration. Please contact Ange at sbia.programs@sasktel.net if you have any questions. If you would prefer to PRINT OFF a registration form instead of completing the online version, please click below. Click HERE to download the Saskatoon BPH Registration Form
