Client Waiver for The Wellness Clinic at Lifequest CLIENT NAME: (first and last name) DATE OF BIRTH: ADDRESS: CONTACT NUMBER: EMAIL: RATE YOUR CURRENT HEALTH STATUS: 1- Poor 2 3 4 5- Excellent I represent to The Wellness Clinic at LifeQuest that I am physically fit to perform those activities which I may undertake at the Club. I am solely responsible for all health risks associated with such activities. I acknowledge that my attendance at or use of the Club or participation in any of the Club’s activities or programs including without limitation to my use of the equipment and facilities, I hereby assume all risks of personal injury, death, property loss, or other damages which may result from or arise from the attendance at or use of the Club or participation in any of the Club’s activities and programs. The foregoing risks shall include, but are not limited to, risks associated with; aerobics, fitness equipment, weight lifting, team and individual sports, exercise, rock wall climbing, locker room, sun tanning, nursery, parking environment, theft, contagion, or any other losses such as personal injuries, property loss, or other damages connected to or arising out of an aforesaid risks. I hereby, on behalf of myself and my heirs, executors, administrators and assigns, fully and forever release and discharge The Wellness Clinic at LifeQuest from any and all claims, damages, demands, rights or action or causes of action, present or future, known and unknown, anticipated and unanticipated, resulting from and arising from my attendance at or use of the Club. Further, I hereby release and discharge the Club from any and all liability for any loss, theft or damage to personal property, including without limitation automobiles and the contents of lockers. HIPAA Notice of Privacy Practices. Protected healthcare information is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related healthcare services. You have the right to inspect and copy your protected health information. You have the right to request a restriction of your protected healthcare information. You have the right to request to receive confidential communications from us by alternative means than any alternative location. You have the right to obtain a paper copy of this information from us. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. You may complain to us or to the Sec. of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. We are required by law to maintain the privacy of and provide individuals with this notice of our legal duties and privacy practice with respect to protected health information. If you have any objections to this form, please speak with our HIPAA compliance officer in person. The health and safety of our members, guests and employees is a top priority for the Clinic. The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, local governments and health agencies recommend social distancing and, in some cases, prohibit the congregation of large groups of people. The Wellness Clinic at LifeQuest (‘the Clinic”) has put in place preventative measures to reduce the spread of COVID-19; however, the Clinic cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, attending the Clinic could increase your risk and your child(ren)’s risk of contracting COVID-19. The Wellness Clinic at LifeQuest follows CDC (Center for Disease control) guidelines of social distancing and sanitation for the protection of all people who enter our facility. If I have any of the following, I understand I am not allowed to enter the facility and I agree to abide by these expectations: • If I have been diagnosed with COVID-19 and have not recovered or am still within the required 14-day quarantine. • If I had symptoms of COVID-19 within the last 24 hours. Or if I experience the following: a fever, cough, shortness of breath, sore throat, loss of taste or smell, vomiting or diarrhea or any other symptoms, I will stay home. • If I had contact with a person who has or is suspected to have COVID-19 within the last 14 days. • I agree to not enter the facility if I am sick. I will cover my cough or sneeze with a tissue and wash my hands. I will not touch my eyes, nose, or mouth and will practice good hygiene. • I will abide by social distancing – stay at least 6 feet away from other people.• I will wear a face covering as required by the State mandates this is subject to change as we move out of the various phases. • I agree to wash my hands upon entrance to the Clinic (if mandated) and frequently with soap and water for at least 20 seconds. Or use hand sanitizer. • I agree to wipe off equipment before and after each use. By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending the Clinic and that such exposure or infection may result in personal injury, illness, permanent disability, and / or death. I understand that the risk of becoming exposed to or infected by COVID-19 at the Clinic may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Clinic employees, volunteers, and program participants and their families. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury (or illness) to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at the Clinic or my participation in Clinic programming (“Claims”). On behalf of me and my children, I hereby release, covenant not to sue, discharge, and hold harmless the Clinic, its owners, employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Clinic, its owners or employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after my participation in any Clinic usage, lesson, class, or program. Waiver and Release: This waiver and release of liability includes, without limitation, all injuries which may occur, regardless of negligence, as a result of: (a) your use of all amenities and equipment in the facility and your participation in any activity, class, program, personal instruction; (b) the sudden and unforeseen malfunctioning of any equipment; (c) our instruction, training, supervision, or dietary recommendations; or (d) your slipping and/or falling while in the clinic, or on the club premises, including adjacent sidewalks and parking areas. This also includes any negligence associated with the presence of or transmission of any bacteria, viruses, or infectious diseases. It is further agreed that if a court of law finds any part of this agreement to be against public policy or in violation of any state statute or legal precedent, then the remainder of this document will remain in full force. Additionally, I understand that The Wellness Clinic at LifeQuest may photograph or videotape client events for social media, live streaming/pre-recorded sessions and by signing below you provide your express written approval for the Club to use these images or video in any and all media for promotional purposes, with no financial or other remuneration due to you. BY CHECKING THIS BOX, I ACKNOWLEDGE I HAVE READ THE ABOVE STATEMENT & AGREE TO UPHOLD THE POLICY ARE YOU INTERESTED IN A COMPLIMENTARY CONSULTATION WITH A CERTIFIED PERSONAL TRAINER? Yes No WHAT HEALTH GOAL(S) DO YOU HAVE? IMPROVE OVERALL HEALTH INCREASE FLEXIBILITY IMPROVE ENDURANCE DECREASE OVERALL DISCOMFORT WEIGHT LOSS INCREASE STRENGTH DECREASE STRESS AND ANXIETY Signature Date Send
