LIVONIA FIRE DEPARTMENT

FITNESS INCENTIVE TESTING PROGRAM MEDICAL RELEASE FORM

I, _____________________________ desire to participate in the voluntary Fitness Incentive

           (print name of Fire Fighter)

Training Program of the Livonia Fire Department, and agree to comply with all rules of the

program.  I understand that a) the program is completely voluntary, b) the purpose is to increase

Fire Fighter fitness for duty, and to allow the Department to study the correlation between fitness

and injury rate/type, and c) the testing process includes push-ups, sit-ups, and a one and one-half

mile timed run, and I certify that I am physically fit and capable of participation.

                                                                                ______________________________

                                                                                       (Fire Fighter’s signature and date)

Test Standards:

I, ____________________________, certify that  _________________________________ is

        (print name of physician)                                          (print name of fire fighter)

physically capable of participating in the Livonia Fire Fitness Incentive Training Program.

                                                                           ________________________________________

                                                                                          (physician signature and date)

FIT_Test_Medical_Release_Form_LFD.doc