In an effort to provide the most safe and effective
programs, we require all clients to complete this
application.
Information contained on this application will
remain confidential. After your application is
reviewed, our office will contact you by e-mail
or phone.
The completion of this application
does not guarantee your participation in our program.
Contact
Information:
About
Your Injury:
Level
of Spinal Cord Injury:
Complete or Incomplete
Diagnosis:
Date of injury:
Asia Level/Score:
How were you injured?
At what hospital were you treated?
City/State:
Treating physician:
Date of Last Medical
Examination:
Describe
your physical abilities
(Be as specific as possible,
particularly with respect
to your legs):
Upper Extremity:
Trunk (IE:
Can you sit up?)
Lower Extremity:
Please
list any physical problems
or special considerations:
(IE:
osteoporosis/osteopenia,
knee instability, joint/muscle
disorder, obesity, hypersensitivity,
rods in back, other health
issues)
Previous
rehabilitation (if any)
Results:
Date
Last Attended:
Have you had
a recent bone density assessment?
Results:
Yes
No
Normal
Other
NOTE:
All clients over 6 months
post injury must obtain
a bone density assessment
and are required to submit
a copy of the bone density
report with the doctor’s
interpretation before
their first session at Journey
Forward. We do not interpret
bone density reports.
Please
list the type, dosage, frequency
and function of all medications
you are taking: (Medication
Type, Dosage mg/day, Type-Function)
Please
answer Yes or No to the following.
Indicate “Yes” for those
that apply to you at present or have
applied to you in the past:
Condition:
Yes
No
History of
chest pain:
History of heart disease
or any other heart/valve
disorder:
Any chronic illness or
condition:
High Blood Pressure:
Low Blood Pressure:
Difficulty with physical
exercise:
Osteoporosis:
Osteopenia:
History of Pathological
fracture:
Advice from your doctor
not to exercise:
Recent surgery (last 12
months, other than SCI):
Pregnancy (now or within
the last 3 months):
Breathing/Lung Problems:
Asthma:
Any other disease of the
lungs:
Muscle, joint or back
disorder, or any previous
injury still affecting you:
Diabetes:
Thyroid condition:
Cigarette smoking:
High Cholesterol:
Obesity:
History of heart problems
in the immediate family:
Hernia, or any condition
that may be aggravated by
intense exercise:
Excercise:
Are
you aware of any disease or disorder
that would complicate your participation
in an exercise program?
(other than the medical conditions
you have checked above)
Yes
No
If yes,
please explain:
Has
your physician approved your participation
in an intense exercise program?
NOTE: This is required prior
to your first session at Journey
Forward.
Yes
No
Are
you accustomed to vigorous exercise?
Yes
No
Is there
any reason not mentioned here
why you should not follow a regular
exercise program? If yes, please
explain:
Yes
No
Please
make any other comments you feel
are pertinent to your exercise
program:
Incase
of Emergency Please Notify:
Name:
Relationship:
Phone (home):
Phone (work):
Terms and Conditions:
I have completed this Application to the
best of my knowledge in order to make known
any diagnosed medical problems or characteristics
that may increase the risk of health problems,
signs or symptoms indicative of health problems
and lifestyle behaviors related to positive
or negative health, which will enable Journey
Forward to determine if medical clearance
is needed before beginning an exercise program.
I understand that if necessary, Journey
Forward reserves the right to request medical
clearance which may involve a bone scan
and physician’s evaluation and approval
before beginning any exercise program, and
has the right to deny my participation in
the program if requests are not fulfilled.
I also understand that participating
in the program at Journey Forward while
under the influence of any uncontrolled
substance (e.g. marijuana) is strictly
prohibited and will result in immediate
termination of my participation in the
program if detected.
AGREEMENT 1. One Week Visit
At Journey Forward every effort is made
to accommodate all schedule changes for
our clients. The capacity of our schedule
dictates our waiting list, therefore last
minute cancellations and constant requests
to reschedule makes it difficult for us
to accommodate all of our clients. The
policy below helps Journey Forward better
serve everyone. Thank you for adhering
to this policy.
1.1 Visit Reservation. To guarantee a
visitation date, Journey Forward requires
an initial deposit of $200 via credit
card due at the time of the reservation
confirmation. The balance of the total
amount due for any visit must be submitted
no later than two (2) weeks prior to the
arrival date. Full payment must be received
prior to the arrival date in order to
hold that date on the schedule. If payment
is not received, Journey Forward will
remove the client from the schedule and
provide notification via email.
All cancellations must be received with
at least two (2) weeks notice or the client
will be charged a non-refundable fee of
$100 taken from the original deposit.
Journey Forward will allow a period of
six (6) months for rescheduling. If cancellation
occurs more than two (2) times in that
six (6) month period, the entire deposit
will be forfeited. If you have not rescheduled
within the six (6) month time period,
the entire deposit will be forfeited.
If cancellation occurs less than two (2)
weeks from the scheduled date, the entire
deposit will be forfeited.
1.2 Initial Consultation. Your initial
consultation will consist of approximately
2.5–3.5 hours. During this time,
we will go over your paperwork, guidelines,
and any questions you may have. Once on
the floor, we will do an evaluation of
your abilities and the remainder of your
appointment working out.
2. Cost of the Program
2.1 Cost of One Week Visit: $100 per hour:
Five (5) sessions at two (2) or three
(3) hours depending on client need and
injury level.
2.2 Ongoing Rates. Current ongoing rate
is $100.00 per hour. The pricing is based
on the number of hours you train per day
per week. Home-based programs are an additional
$300. Rates are subject to change at any
time.
3. Payment Schedule for All Clients of
Journey Forward, All rates are calculated
on a monthly basis. Payment by cash, check,
VISA or MasterCard is due on the first
of each month. A $100 late fee will apply
if payments are not received by the 3rd
day of each month and a $75 fee for returned
checks. Except as otherwise provided herein,
there are no refunds.
4. Waiver of Liability
4.1 Waiver/Indemnification. Client acknowledges
that any activities client participates
in can be an extreme test of client physical
and mental limits and carry the potential
for severe physical injury. Client hereby
assumes the risks of participating in
any and all of Journey Forward activities
and functions. Client certifies that client
is able to participate in the Journey
Forward program and has not been advised
otherwise by a qualified medical person.
Client understands that the information
and treatments obtained by participating
in Journey Forward do not constitute medical
treatment, diagnosis or advice. Client
understands that client should seek the
advice of a physician or other qualified
health provider if client has questions
about a medical condition. Client understands
that a bone density scan is required to
enter Journey Forward and client agrees
and acknowledges that Client will have
taken such bone density test and shared
the results of such test with Journey
Forward before beginning any treatments
with Journey Forward. Client certifies
that in consideration of becoming a client
of the program, Client hereby takes the
following action for itself, its executors,
administrators, heirs, next of kin, successors
and assigns:
Client waives, releases and discharges
from any and all claims or liabilities
for any loss, damage, theft or injury
of any kind which arise out of or related
to its participation in, or its traveling
to and from the Journey Forward center;
including, but not limited to, 1) any
known and unknown, foreseen and unforeseen
bodily and personal injury, 2) loss of
life, and 3) any attorney’s fees,
costs, expenses, or charges sustained,
directly or indirectly, or alleged to
have been sustained, or in any fashion
arising from, in connection with, or resulting
from its participation in Journey Forward,
even if due to the negligence of Journey
Forward or any employee, volunteer, director,
officer, client, owner or agent thereof.
Client will indemnify and hold harmless
Journey Forward any and all employees,
volunteers, directors, officers, clients,
owners and agents thereof from any claim,
demand and/or cause of action of any nature
whatsoever, related to Client’s
participation in Journey Forward even
if due to the negligence of Journey Forward,
including, but not limited to any and
all losses, liabilities, damages, costs
and expenses (including reasonable attorney
fees) arising out of such actions.
Client will indemnify and hold harmless
Journey Forward any and all employees,
volunteers, directors, officers, clients,
owners and agents thereof from any claim,
demand and/ or cause of action of any
nature whatsoever, related to Client’s
participation with off duty Journey Forward
employees, volunteers, directors, officers,
clients, owners and agents (the individuals)
in any and all personal activities not
related to the individuals’ function
as representatives of Journey Forward.
4.2 Termination of Services. Journey Forward
reserves the right to terminate the service
relationship with clients at any time,
for any reason, with or without cause
or notice and with no further liability
to Client. No oral or written statement
shall limit the right to terminate the
service relationship.
4.3 Consent to Use of Materials. By signing
this Agreement and joining Journey Forward,
you give Journey Forward a perpetual,
worldwide, royalty-free, sublicenseable,
assignable license to use your name, voice,
visual likeness, photographs and film
of you (collectively, the "Materials")
to use, adapt, modify, reproduce, distribute,
publicly perform and display, in brochures,
advertisements, commercials, on the Journey
Forward website and in any form now known
or later developed throughout the world.
Client understands and agrees that Journey
Forward shall be the exclusive owner of
all title and interest, including copyright,
in any and all works containing the Materials.
4.4 Authorization. Client understands
that client is personally responsible
to pay all charges for services rendered
to it and agrees to make payment thereof
when due. Any billing sent by Journey
Forward to an insurance company, attorney,
or other third party is for the accommodation
of the Client and does not relieve the
undersigned to pay charges for the services
provided. Client authorizes any holder
of medical information about it to release
to its insurance carrier and its agents
any information needed to determine these
benefits. Client authorizes payment for
these services to be paid directly to
Journey Forward.
Client hereby confirms that he/she is
18 years of age or older, he/she has read
this document and understand its contents.
If under 18, a parent or guardian must
sign. Client acknowledges that he/she
has read, understands, and agrees to the
terms and conditions of this Agreement.
Release of Liability, Assumption of Risk
and Indemnity Agreement for Clients with
Diagnosed or Undiagnosed Osteoporosis
or Osteopenia I understand that osteoporosis
is a disease in which bones become fragile
and more likely to break. If not prevented
or if left untreated, osteoporosis can
progress painlessly until a bone breaks.
These broken bones, also known as fractures,
occur typically in the hip, spine and
wrist.
Any bone can be affected, but of special
concern are fractures of the hip and spine.
A hip fracture almost always requires
hospitalization and major surgery. It
can impair a person's ability to walk
unassisted and may cause prolonged or
permanent disability or even death. Spinal
or vertebral fractures also have serious
consequences including, but not limited
to, loss of height, severe back pain and
deformity.
By reading and signing this document,
I acknowledge that I have been diagnosed
with osteoporosis or osteopenia (low bone
density) and I understand I am at high
risk for fractures. I also understand
that the Journey Forwards program requires
strenuous physical activity and/or intense
exercise in which there are potentially
serious risks and dangers including, but
not limited to, fractures, disability
or even death as described above.
In light of the above information, I,
the undersigned participant, am requesting
voluntary participation in the Journey
Forward program. I have obtained appropriate
medical insurance that will provide for
medical treatment in case of accident,
illness or injury for the duration of
the program. Furthermore, I will use my
personal medical insurance as a primary
medical coverage payment if accident or
injury occurs
Release of Liability, Assumption of Risk,
and Indemnity Agreement
RELEASE: In consideration for being permitted
to participate in the program for spinal
cord-injured clients at Journey Forward
that I have enrolled in with a current
diagnosis of osteoporosis or osteopenia,
I do hereby release and hold harmless,
forever discharge and covenant not to
sue Journey Forward its owners, officers,
staff, employees and/or the agents of
each of them, from and against any and
all liabilities, claims and causes of
action including, but not limited to,
negligence, by reason of any personal
injury, accident, illness, death or property
loss or any other consequence resulting
directly or indirectly from or in any
manner arising out of, or in connection
with, my being a participant in the Journey
Forward program.
ASSUMPTION OF RISK: Participation in
the Journey Forward program carries with
it certain inherent risks that cannot
be eliminated regardless of the care taken
to avoid injuries. The specific risks
vary from one activity to another, but
the risks range from 1) minor injuries
such as scratches, bruises, and sprains
to 2) major injuries such as bone fractures,
joint or back injuries, heart attacks,
and concussions to 3) catastrophic injuries
including further paralysis and death.
INDEMNIFICATION: I also agree to indemnify
Journey Forward. and its owners, staff,
employees, and agents in connection with
any and all claims, actions, suits, procedures,
costs, expenses, damages and liabilities
including, but not limited to, attorney’s
fees, brought as a result of my involvement
in the Journey Forward program and to
reimburse them for any such expenses incurred.
I HAVE READ THE PREVIOUS PARAGRAPHS AND
I KNOW, UNDERSTAND, AND APPRECIATE THESE
AND OTHER RISKS THAT ARE INHERENT IN THE
JOURNEY FORWARD PROGRAM. I HEREBY ASSERT
THAT MY PARTICIPATION IS VOLUNTARY AND
THAT I KNOWINGLY ASSUME ALL SUCH RISKS
AND ENTER INTO THIS RELEASE, ASSUMPTION
OF RISK AND INDEMNITY AGREEMENT VOLUNTARILY.
I FURTHER UNDERSTAND AND AGREE THAT THIS
AGREEMENT SHALL ALSO BE BINDING ON MY
HEIRS, ASSIGNS, SUCCESSORS, AND ALL OTHER
PERSONS WHO MAY CLAIM THROUGH ME.
Severability: The undersigned further
expressly agrees that the foregoing release,
assumption of risk and indemnity agreements
are intended to be as broad and inclusive
as is permitted by the law of the State
of Massachusetts and that if any portion
thereof is held invalid, it is agreed
that the balance shall, notwithstanding,
continue in full legal force and effect.
Acknowledgment of Understanding: I have
read this release of liability, assumption
of risk, and indemnity agreement, I fully
understand its terms, and I understand
that I am giving up substantial rights,
including my right to sue. I acknowledge
that I am signing the agreement freely
and voluntarily, and intend by my signature
to be a complete and unconditional release
of all liability to the greatest extent
allowed by law.