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Participants acknowledge program goals, gradual fitness progression based on perceived effort, and responsibility for monitoring symptoms and informing the instructor and physician. The packet authorizes collection, use, and disclosure of health information to the YMCA and YMCA of the USA for administration, evaluation, approved research, outcome tracking, and grant reporting, with HIPAA-related disclosures, revocation rights, and termination timing.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/livestrong-at-the-ymca-consent-and-release-from-liability-authorization-and-informed-consent-packet-oct-2019/178247/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/livestrong-at-the-ymca-consent-and-release-from-liability-authorization-and-informed-consent-packet-oct-2019/178247.png","ImageObject",442,249,{"name":88,"@type":89},"Oliver Hayes","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/vnd.openxmlformats-officedocument.wordprocessingml.document","2026-10-23","2026-09-02",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",8,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What does the participant assume and agree to under the consent and release from liability section?","Question",{"text":109,"@type":110},"The participant voluntarily joins the program, monitors their own condition, stops participation if symptoms occur, and assumes the risk of physical activity. They also agree to hold harmless the YMCA and its staff from claims related to injury or death arising from participation.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"Why must participants consult a physician before starting the LIVESTRONG at the YMCA program?",{"text":114,"@type":110},"The participant agrees to consult a physician and obtain written permission before the program begins. The documents also clarify that the YMCA and instructors do not practice medicine and do not replace care from qualified health care providers.",{"name":116,"@type":107,"acceptedAnswer":117},"What health information does the authorization allow the YMCA to disclose, and for what purposes?",{"text":118,"@type":110},"The authorization covers health information collected in connection with the program. Disclosures are for program administration, operation and evaluation, approved IRB research, tracking/verifying health outcomes, and fulfilling grant reporting requirements, which may involve re-disclosure of de-identified or aggregate information.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},178247,1791234691,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":79,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":73},687207020761,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","DISCLAIMER\nThis authorization template is for general information purposes only. This authorization template provides sample language for covered entities as defined under the Health Insurance Portability and Accountability Act (HIPAA). Data privacy and security laws change frequently. This authorization template is not a substitute for legal advice. You should not use this authorization template without first seeking guidance from your legal counsel.\nLIVESTRONG® at the YMCA CONSENT AND RELEASE FROM LIABILITY\nI hereby consent to voluntarily participate in LIVESTRONG at the YMCA with the YMCA of Catawba Valley (YMCA). I understand the goal of the program is to help adult cancer survivors develop and maintain cardiorespiratory fitness, muscular strength and endurance, flexibility and balance. The program is designed to gradually increase workload on the body to improve overall fitness. The rate of progression is regulated by the rate of my perceived effort of activity. I understand I am responsible for monitoring my own condition throughout the program and should any symptoms occur, I would cease my participation and inform the Instructor and my physician of the symptoms.\nI agree to consult my physician and obtain written permission from my physician prior to the commencement of the LIVESTRONG at the YMCA Program. I understand the YMCA does not practice medicine and LIVESTRONG at the YMCA is not a substitute for the care I receive from my physician or other qualified health care providers. I understand the LIVESTRONG Instructor is not a qualified health care professional, does not practice medicine, and support provided by the Instructor is not a substitute for the care I receive from my qualified health care providers.\nIn consideration for being allowed to participate in this program, I agree to assume the risk of such physical activity, and further agree to hold harmless the YMCA, its employees and agents, from any and all claims, suits, losses or related causes of action for damages, including, but not limited to, such claims that may result in my injury or death, accidental or otherwise, during or arising in any way from my participation in the LIVESTRONG at the YMCA Program.\nBy signing below, I affirm that I have read the above in its entirety, and I understand the nature of the LIVESTRONG at the YMCA Program. I also affirm that my questions regarding the program have been answered to my satisfaction.\nSignature of participant: _________________________________    Date: _____________\nAUTHORIZATION FOR\nUSE AND DISCLOSURE OF HEALTH INFORMATION\nI authorize the YMCA of Catawba Valley (YMCA) located at 701 1st St NW, Hickory, NC 28601 to collect and use data in connection with my participation in the LIVESTRONG at the YMCA Program, maintain this data in a data capture system, and disclose (i.e., share) this data to the YMCA of the USA (Y-USA) located at 101 N. Wacker Drive, Chicago, IL 60606.\nData/Information to be disclosed:\nHealth information collected in connection with the LIVESTRONG at the YMCA Program\nThe purposes of the disclosure include:\nProgram administration, operation, and evaluation\nResearch activities approved by an Institutional Review Board (IRB)\nTo enter into the YMCA’s data system for LIVESTRONG at the YMCA for purposes of tracking and verifying health outcomes related to the LIVESTRONG at the YMCA Program\nWhen applicable, to fulfill applicable grant reporting requirements. This may require the re-disclosure of de-identifiable and/or aggregate health information to a third-party, including government entities (e.g., the U.S. Centers for Disease Control and Prevention)\nBy signing below:\nI authorize the use and disclosure of my health information as described above for the purposes indicated.\nI understand I have the right to receive a copy of this authorization.\nI understand the YMCA will not condition my participation in the LIVESTRONG at the YMCA Program on my providing this authorization.\nI understand the YMCA ","cbCaiiC8BN5ihVt4","https://ap.wps.com/l/cbCaiiC8BN5ihVt4","docx",51977,"English","# Consent and Release From Liability\n## Program participation responsibilities\n## Physician consultation and medical disclaimers\n## Assumption of risk and hold harmless\n# Authorization for Use and Disclosure of Health Information\n## Data collection, use, and sharing\n## Purposes: administration, research, outcomes, grant reporting\n## Participant rights, revocation, and termination\n# Authorization for Release of Information to Health Care Provider","[{\"question\":\"What does the participant assume and agree to under the consent and release from liability section?\",\"answer\":\"The participant voluntarily joins the program, monitors their own condition, stops participation if symptoms occur, and assumes the risk of physical activity. They also agree to hold harmless the YMCA and its staff from claims related to injury or death arising from participation.\"},{\"question\":\"Why must participants consult a physician before starting the LIVESTRONG at the YMCA program?\",\"answer\":\"The participant agrees to consult a physician and obtain written permission before the program begins. The documents also clarify that the YMCA and instructors do not practice medicine and do not replace care from qualified health care providers.\"},{\"question\":\"What health information does the authorization allow the YMCA to disclose, and for what purposes?\",\"answer\":\"The authorization covers health information collected in connection with the program. Disclosures are for program administration, operation and evaluation, approved IRB research, tracking/verifying health outcomes, and fulfilling grant reporting requirements, which may involve re-disclosure of de-identified or aggregate information.\"}]","LIVESTRONG at the YMCA Consent and Release From Liability - Authorization and Informed Consent Packet Oct 2019 | DOCX",1788330928]