I understand that the nutrition counseling provided is not medical treatment or substitute for any treatment. I have provided truthful personal medical data and am seeking nutritional counseling with the approval of my physician. I understand nutrition counseling is voluntary and that I may discontinue participation at any time without penalty or prejudice toward me.
By signing my name below I further certify that I have read and understood the terms and conditions of this agreement and intent to legally be bound by it.
I authorize the release of my pertinent health/nutrition/fitness information between the Registered Licensed Dietician and Personal Training/Fitness Assessment staff for the purpose of developing a comprehensive nutrition and fitness plan.
It is the aim of the Department of Campus Recreation and Intramural Sports to give you, the Patron, the best services that we can. Please help us by filling out this questionnaire so we may fulfill your expectations of a successful nutrition assessment/session. If you answer "Yes" to any of these questions, we may ask that you consult your Physician for clearance.
Department of Campus RecreationWellness Resource Center
(330) 941-2241Front Desk
(330) 941-3488Campus Recreation and Wellness Centerysunutrition@hotmail.com