WaiverForever

CONSENT AND RELEASE FORM FOR HEALTH SCREENING  1. Purpose of the Screening. The primary purpose of this health screening is to increase awarenessand knowledge of personal health and wellness, inform and refer participants to specific wellnessresources, assist with establishing and achieving health goals, and promote programs and services that enhance wellness. As a participant, you will have the opportunity to complete a health risk assessment(HRA). Completion of the HRA is voluntary and failure to participate will not jeopardize your employment status in any way.2. Explanation of the Screening and Associated Risks. This health screening will include one or moreof the following tests:  taking of a small blood sample drawn by needle from your arm for the bloodchemistry analysis, a blood pressure check, strength testing, aerobic fitness testing, and a body composition analysis that may involve skinfold measurements. You could experience symptoms during this health screening such as abnormal blood pressure, fainting, irregular, or fast or slow heart rhythm that may, in rare instances, lead to a heart attack, stroke, or other serious healthcondition, or even death. Emergency personnel and equipment [are/are not] on site to deal immediately with these situations should they arise. You are strongly encouraged to ask questions of the screening staff if you do not understand the risks or the procedures to be performed.3. Confidentiality and Use of Personal Information. By participating in this health screening andcompleting an HRA, you are granting permission to [Company] to use the information for programdevelopment, evaluation, and emergency follow up if warranted, in the solediscretion of [Company]. You may revoke this authorization of consent by providing written notice to[Company] at any time. Any personally identifiable health information obtained in conjunction withyour health screening and HRA will be protected and will only be used in accordance with this consent/agreement and applicable laws pertaining to the use of personal health information. Your information in aggregate form may be used for research, educational, or statistical purposes so long as the data does not personally identify you. Please fill in your name Gender Please fill in your email Please fill date Please fill in your address Your signature