Mohawk Valley Wellness Liability Waiver (12695)
Mohawk Valley Wellness , Inc. 9647 River Road, Marcy New York 13403 Name:__________________________________ Email: ________________________________ Address: ________________________________ City, State, Zip: _________________________ Date of Birth: ____________________________ Phone Number # : _______________________ In an emergency, I would like Mohawk Valley Wellness to call : ____________________________ Phone: _________________________________ Waiver and Hold Harmless Agreement Express assumption of risk : I, the undersigned, hereby assume all of the risks of participating in physical training at and, I am aware that there are significant risks involved in all aspects of physical training. These risks include, but are not limited to: falls which can result in serious injury or death; injury or death due to negligence on the part of myself, my training partner, or other people around me; injury or death due to improper use or failure of equipment; strains, and sprains. I am aware that any of these above mentioned risk may result in serious injury or death to myself and or my partner(s). I willingly assume full responsibility for the risks that I am exposing myself to and accept full reasonability for any injury or death that may result from participation in any activity or class while at, or under of Initials: ______________ Further, I acknowledge that I am physically fit to begin physical training and that I have no physical impairments, injuries, or illness that will endanger me or others. I have not been advised to not participate by a qualified medical professional. I certify that there are no health-related reasons or problems which preclude my participation in this activity. Initials: ______________ ( ) I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, liability arising from the negligence or fault of the entities or persons released, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me. In consideration of the above mentioned risks and hazards and in consideration of the fact that I am willingly and voluntarily participating in the activities offered by ., I the undersigned hereby release Inc., their principals, agents, employees, and volunteers from any and all liability, claims, demands, actions or rights of action, which are related to, arise out of, or are in any way connected with my participation in this activity, including those allegedly attributed to the negligent acts or missions of the above mentioned parties. It is my express intent that this agreement shall be binding upon me, my successors, representatives, heirs, executors, assigns, or transferees. If any portion of this agreement is held invalid, I agree that the remainder of the agreement shall remain in full legal force and full effect. Initials: ______________ Indemnification: The participant recognizes that there is risk involved in the types of activities offered by Inc. Therefore the participant accepts financial responsibility for any injury that the participant may cause to either him/herself or to any other participant due to his/her negligence. Should the above mentioned parties, or anyone acting on their behalf, be required to incur attorney’s fees and cost to enforce this agreement, I agree to reimburse them for such fees and cost. I further agree to indemnify and hold harmless Inc., their principals, agents, employees and volunteers from liability for the injury or death of any person(s) and damage to property that may result from my negligent or intentional act or omission while participating in activities offered by Inc., at the main building or abroad. This includes but is not limited to parks, recreational areas, playgrounds, areas adjacent to the main building, and/or any area selected for training by Inc., their principals, agents, employees and volunteers. I acknowledge that this activity may involve a test of a person’s physical and mental limitations and may carry with it the potential for death, serious injury, and/ or property loss. The risks may include, but are not limited to, those caused by terrain, facilities, temperature, weather, conditions of participants, equipment, vehicular traffic, actions of other people including but not limited to participants, volunteers, spectators, coaches, and lack of hydration. I hereby consent to receive medical treatment which may be deemed advisable in event of injury, accident and/or illness during this activity. If I am signing of the behalf of a minor child, I also give full permission for any person connected with to administer first aid deemed necessary for the well being of the child. Initials: ______________ I understand that I may be photographed while at or one of it’s events. I agree to allow my photo, video, or film likeness to be used for any legitimate purpose with out compensation, on the website, or in any editorial promotional or advertising material produced and/or published by Inc. Initials:________________ In signing this Waiver and Hold Harmless Agreement, I acknowledge and represent that I have READ the forgoing Waiver and Hold Harmless Agreement, UNDERSTAND IT and SIGN IT VOLUNTARILY as my own free act and deed and I execute this Waiver and Hold Harmless Agreement for full, adequate and complete consideration fully intending to be bound by the same. I further understand that by singing it obligates me to indemnify the parties named for any liability for injury or death or any person and damage to the property caused by my negligent or intentional act or omission. I understand that by signing this form I am waiving my valuable legal rights. Signature of participant: ______________________________________________ Date: ___________________________________ If the participant is under the age of 18. Signature of parent/guardian: _________________________________________Print Name ______________________Date:___________ Reviewed by: (Print) ___________________________________________ Signature:___________________________ Date:___________ Mohawk Valley Wellness Inc. 9647 River Road , Marcy New York 13403 Name:__________________________________ Email: ________________________________ Address: ________________________________ City , State, Zip: _________________________ Date of Birth: ____________________________ Phone Number # : _______________________ In an emergency, I would like to call : ____________________________ Phone: _________________________________ Health Questions Do you Smoke? Y N Drink Alcohol? Y N Take Prescription medications? Y N Are you exercising now? Y N Days per week? ________ Do you participate in sports Y N Do you have high blood pressure, asthma, diabetes, or a heart condition? Y N Do you have any other health conditions not listed? Y N Are you under any physical restrictions from a doctor of physician? Y N Do you have a doctor’s or physician’s consent to begin physical training? Y N Photography / Video Release Participants involved in any activities offered by Inc. may be photographed or videotaped during training. The undersigned herby consents to the use of these photographs and/or videos by Mohawk Valley Wellness.
* Please use your mouse/finger to sign your name