Client Intake Form (Page 2 of 4) in pdf

FORM B ODY L AB

RELEASE O F L IABILITY, W AIVER O F C LAIMS A ND A SSUMPTION O F R ISKS A GREEMENT

(“Agreement”)

PLEASE R EAD T HIS A GREEMENT C AREFULLY. B Y S IGNING T HIS A GREEMENT Y OU W ILL W AIVE

CERTAIN L EGAL R IGHTS, I NCLUDING T HE R IGHT T O S UE O R C LAIM C OMPENSATION F OLLOWING A N

ACCIDENT.

To: F orm B ody L ab L td., S tellar P roperties L td. a nd t heir d irectors, o fficers, e mployees, a gents,

independent c ontractors, s upplies, s uccessors, a ssigns a nd r epresentatives ( “Releasees”).

Definition: I n t his A greement, t he t erm “ Wellness A ctivities” s hall i nclude a ll a ctivities, c lasses,

instruction a nd s ervices p rovided, a rranged, o rganized, c onducted, o r a uthorized d irectly o r i ndirectly

by o r o n b ehalf o f a ny o ne o r m ore o f t he R eleasees a nd s hall f urther i nclude, b ut i s n ot l imited t o:

yoga a nd p ilates c lasses o r i ndividual s essions, u se o f a ny e quipment p rovided b y o ne o r m ore o f t he

Releasees ( “Equipment”) a nd a ny o ther a ctivities, c lasses, i nstruction a nd s ervices i n a ny w ay

connected t herewith.

PAR-‐Q a nd M edical C learance

A. I c ertify t hat m y r esponses o n t he P AR-‐Q f orm a re t rue a nd c omplete t o t he

best o f m y k nowledge.

INITIAL:

B. I a cknowledge t hat m edical c learance i s s trongly r ecommended i f I h ave

answered “ yes” t o a ny o f t he q uestions o n t he P AR-‐Q f orm.

INITIAL:

C. I a cknowledge t hat I h ave a nswered “ yes” t o o ne o r m ore q uestions o n t he

INITIAL ( if

PAR-‐Q f orm a nd I h ave b een a dvised b y t he C ompany t o s eek m edical

applicable):

clearance. I a m a ware o f m y l imitations a nd h ave d ecided t o p articipate i n

INITIAL ( if

Wellness A ctivities w ithout s eeking m edical a dvice. I a m a ware t hat t his m ay

not

place m e a t g reater r isk o f i njury a nd a ssume a ny a dditional r isk.

applicable):

Assumption o f R isks

I a m a ware t hat p articipating i n W ellness A ctivities i nvolves r isks, d angers a nd h azards t hat i nclude,

but a re n ot l imited t o: m echanical f ailure o f a ny E quipment; i mproperly a djusted o r m aintained

Equipment; n egligent d esign o r m anufacture o f E quipment; h ealth r isks i ncluding, b ut n ot l imited t o,

overexertion, d ehydration, f atigue, h eart a ttack, s troke, s trains/sprains, b roken b ones, s hin s plints,

joint i njuries; a nd N EGLIGENCE A ND G ROSS N EGLIGENCE O N T HE P ART O F T HE R ELEASEES,

INCLUDING F AILURE O N T HE P ART O F T HE R ELEASEES T O T AKE R EASONABLE S TEPS T O P ROTECT O R

SAFEGUARD M E F ROM T HE R ISKS, D ANGERS, A ND H AZARDS ( a) O F P ARTICIPATING I N W ELLNESS

ACTIVITIES R EFERRED T O A BOVE A ND ( b) A SSOCIATED W ITH T HE U SE O F, O R F AILURE T O

MAINTAIN, T HE E QUIPMENT. I F REELY A CCEPT A ND F ULLY A SSUME A LL S UCH R ISKS, D ANGERS A ND

HAZARDS A ND T HE P OSSIBILITY O F P ERSONAL I NJURY, D EATH, P ROPERTY D AMAGE O R L OSS

RESULTING T HEREFROM.

Release o f L iability, W aiver o f C laims a nd I ndemnity

In c onsideration o f t he R eleasees a greeing t o m y p articipation i n W ellness A ctivities a nd p ermitting

my u se o f t heir s ervices, E quipment a nd f acilities, a nd f or o ther g ood a nd v aluable c onsideration, t he

receipt a nd s ufficiency o f w hich i s a cknowledged, I h ereby a gree a s f ollows:

TO W AIVE A NY A ND A LL C LAIMS t hat I h ave o r m ay i n t he f uture h ave a gainst t he R eleasees

AND T O R ELEASE T HE R ELEASEES f rom a ny a nd a ll l iability f or a ny l oss, d amage, e xpense o r

injury, i ncluding d eath, t hat I m ay s uffer o r t hat m y n ext o f k in m ay s uffer, a s a r esult o f m y

participation i n W ellness A ctivities o r u se o f t he E quipment, D UE T O A NY C AUSE

WHATSOEVER, I NCLUDING N EGLIGENCE A ND G ROSS N EGLIGENCE, B REACH O F C ONTRACT,

OR B REACH O F A NY S TATUTORY O R O THER D UTY O F C ARE, I NCLUDING A NY D UTY O F C ARE

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