I,

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1. Acknowledge that as a participant in the Heart Health Program provided by Corporate Health Management
   (CHM) on behalf of the Department of Veterans’ Affairs (DVA), I may acquire information that is, by its
   nature confidential or personal information regarding other group program participants

2. Agree:

   • to keep all confidential and personal information that I acquire during the group program, if a participant in this delivery method, confidential

   • not to disclose (to any person) copy or use the confidential or personal information unless authorised
     by DVA or the owner of the information

   • to indemnify DVA and CHM for any loss arising from a breach of this Deed

3. Consent to the DVA using any de-identified data for research purposes

4. Understand that I will be undertaking physical activity and acknowledge that I have gained medical clearances
   from my general practitioner and other relevant professionals to participate in the Heart Health Program

5. Have informed CHM of any issues regarding my physical activity status

6. Understand there are possible risks involved in my participation of the program

7. Understand that DVA and CHM are not responsible for any injuries that may result in my participation in the
   Heart Health Program

8. Accept that no information regarding my medical history will be disclosed to any person other than persons
   who have a need to know for the purposes of delivery of the program

9. ) Understand that I should attempt to attend at least 80% of the group program activities or health coaching calls as a participant on the program.

Please enter your name, date of birth and check the box to confirm you have read and agree to the above (required)

D.O.B:

I have read and agree to the above statement:

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