MEDICAL WAIVER, RELEASE OF LIABILITY FORM

WAIVER, RELEASE OF LIABILITY, AND CONSENT TO MEDICAL ATTENTION

I desire to voluntarily participate in a BodyGarage Dayton wellness program in an attempt to improve my physical health, performance level, and or functional skills.

I understand that the activities, services, varying health equipment and conversations at BODYGARAGE DAYTON are not intended to diagnose, treat, prescribe or fix any illness or injury that I may have, have sustained or may attempt to describe while at BODYGARAGE DAYTON.

I also understand and realize that there is a certain level of risk with the assessment and subsequent health and wellness program, and that my body’s response to the various health equipment or activities cannot be predicted with complete accuracy.

I, hereby state that to the best of my knowledge I have no medical or physical conditions that may affect or restrict me from participating in a BodyGarage Dayton health and wellness program or activity.

I wish to participate in the wellness programs provided by BodyGarage Dayton. I also, hereby give my physician permission to release any pertinent medical information to BodyGarage Dayton and its staff. I agree to consult my physician and obtain written medical clearance (if required), prior to participation in any of the above mentioned programs.

I acknowledge that any initial assessment or personal wellness program, and or exercise is an extreme test of an individual’s physical and mental limits and carries with it the potential for death, serious injury, or property loss.

I HEREBY ASSUME THE RISKS OF PARTICIPATING IN ANY FACILITY, PROGRAM OR EQUIPMENT USE AT BODYGARAGE DAYTON.

I hereby take the following actions for myself and my executors, administrators, heirs, next of kin, successors, and assigns:

a.) I WAIVE, RELEASE, AND DISCHARGE from all claims or liabilities for death or personal injury or damages of any kind, except that which is the result of gross negligence and/or wanton misconduct of persons or entities listed below, which arise out of or relate to my participation with THE FOLLOWING PERSONS OR ENTITIES: any and all staff or employees of BodyGarage Dayton, sponsors, and the officers, representatives, and agents of the above;

b.) I AGREE NOT TO SUE any of the persons or entities mentioned above for any of the claims or liabilities that I have waived, released, or discharged herein; and

c.) I INDEMNIFY AND HOLD HARMLESS THE persons mentioned above from any claims made or liabilities assessed against them as a result of my actions.

I agree that BodyGarage Dayton (including its organizations, directors, officers, sponsors, employees, agents, successors, and assigns) may, but have no duty to provide me, through medical personnel of their choice, customary medical or training assistance, transportation, and emergency medical services.

I HAVE READ THIS WAIVER, RELEASE OF LIABILITY, AND CONSENT TO MEDICAL TREATMENT AND I UNDERSTAND ITS CONTENT.

IF THE PERSON PARTICIPATING IN THE ACTIVITY IS NOT YET 18 YEARS OLD: AS A PARENT OR LEGAL GUARDIAN OF THE NAMED INDIVIDUAL, I VERIFY THAT I FULLY AGREE TO, UNDERSTAND, AND ACCEPT ALL PROVISIONS OF THIS WAIVER, RELEASE OF LIABILITY, AND CONSENT TO MEDICAL TREATMENT.

 
*
Name *
Name
Date *
Date
Address
Address