Exercise Buddy Program sign-up

The Sunflower Wellness Exercise Buddy Program provides an easy way to find someone for you to exercise with.

The program will try to find a match who lives near you interested in the same kinds of exercise as you, and who has comparable abilities and requirements to you.

Why? Because as you might already know, it can be much easier to maintain an exercise program with a "buddy" than alone. And Sunflower Wellness wants to help make your path to exercise as easy as possible.

Whether you're trying to find someone who will attend classes with you, walk with you, or go to the gym with you, we will work to help find you the right match.

PLEASE NOTE: We are currently operating this program only in the San Francisco Bay Area in California.

To sign up for the Buddy Program, please fill in all information on the secure form below.

Name* :
E-Mail address* :
Your phone number:
Your street address:
Your city:
Your state:
Your zip code:
Type of cancer diagnosed:
Please enter additional information about yourself here:
Please describe your physical limitations (if any):
What days and times of the week do you prefer to exercise?
What level of exercise do you currently maintain?	Gentle only Low (once per week) Medium (2 - 3 times per week) High (4 - 7 times per week)
What activities do you currently participate in?
Please enter any specific buddy requests here:
I prefer a buddy who is:	Male Female Don't care
Any other specific match requirements?
Agreement to Terms and Conditions	Sunflower Wellness Exercise Buddy Program Terms and Conditions 1. INVITATION You are invited to participate in the Sunflower Wellness Exercise Buddy Program, designed to help people living with cancer. You are invited to take part either because you have received an Exercise Counseling session or because you are participating in one of our exercise programs. Many people who exercise find it beneficial to work with a buddy to stay motivated to keep exercising. Your participation in this program is strictly voluntary. You may decide to end your participation at any time for any reason. 2. WHAT IS THE PURPOSE OF THIS PROGRAM? The purpose of the Sunflower Wellness Exercise Buddy Program is to match everyone who signs up with a suitable “buddy” to help maintain an exercise program. The program is intended to link you with another person looking for an exercise partner who is also living with cancer to help keep you both motivated. 3. WHAT WILL MY PARTICIPATION INVOLVE? If you decide to participate in this program you will provide Sunflower Wellness with your contact information, as well as brief information that will help us find a “buddy” that will best be able to work with you and suit your requirements. By signing up, you will allow Sunflower Wellness to match you with another cancer survivor. We will also collect the following information about you for this program: a. From you: birthdate, age, home address, phone number, email address, exercise habits, buddy gender preference, brief cancer history, and current basic medical issues. b. We do not collect or keep any other information related to your medical records. 4. HOW TO CONTACT US. If you have any questions related to this program, or our collection or use of your personal information, we invite you to contact us online at https://www.sunflowerwellness.org/SitePages/FeedbackV2.php, or by US mail at the address below: Sunflower Wellness 234 Grand View Ave. San Francisco, CA 94114 5. WILL I BE PAID FOR MY PARTICIPATION? This is a voluntary program. You will not be paid for your participation in this program. Also, the program is provided at no charge. 6. ARE THERE ANY SIDE EFFECTS OR RISKS TO ME? There are always risks involved in undertaking physical exercise. You should consult with your physician prior to beginning any program of exercise. 7. HOW WILL MY PRIVACY BE PROTECTED AND WHO WILL USE MY HEALTH INFORMATION? We will maintain personal health information in a secure database. By agreeing to these Terms and Conditions, you agree that Sunflower Wellness, including its contractors and affiliates, may share the health information collected from you when you sign up for the Buddy Program with any of the following people at Sunflower Wellness and its affiliates who may need to use your health information in the course of this program: a. Trainers and instructors who work with Sunflower Wellness b. Others outside of Sunflower Wellness and its affiliates who may receive your health information in the course of this program, including exercise class providers and individual personal trainers who work with the participant, and also including academic research investigators. People outside Sunflower Wellness and its affiliates who receive your health information may not be covered by privacy laws and may be able to share your health information with others without your permission. In the few instances that we share information from our programs with others outside Sunflower Wellness and its affiliates, it is shared in a way that cannot identify any individual without their express permission. 8. IS MY PERMISSION VOLUNTARY AND MAY I CHANGE MY MIND? Your permission is voluntary. You do not have to sign this form and you may refuse to do so. If you refuse to sign this form, however, you cannot take part in the Sunflower Wellness Buddy Program. You may completely withdraw from the program at any time. 9. HOW LONG WILL MY PERMISSION TO USE MY HEALTH INFORMATION LAST? By agreeing to these Terms and Conditions, you are giving Sunflower Wellness permission to use and share your health information with the individuals or institutions described in this form. Unless you withdraw your permission in writing to stop the use or sharing of your health information, there is no end date for its use for this program. You may withdraw your permission at any time by writing to the address listed below: Sunflower Wellness 234 Grand View Ave. San Francisco, CA 94114 Beginning on the date you withdraw your permission, no new information about you will be used. Any information that was shared before you withdrew your permission will continue to be used. If you withdraw your permission, you can no longer actively take part in this program. 10. WHO SHOULD I CONTACT IF I HAVE QUESTIONS? Please take as much time as you need to think over whether or not you wish to participate. If you have any questions about this program at any time, please contact Sunflower Wellness at https://www.sunflowerwellness.org/SitePages/FeedbackV2.php or at the address listed above.
I have read and agree to the Sunflower Wellness Exercise Buddy Program Terms and Conditions.