Health and Fitness Liability Waiver /Informed Consent Form
I, _______________________________, have enrolled in a program offered through Beth Auguste MS RD CSOWM, I recognize that the program may involve strenuous physical activity including, but not limited to, muscle strength and endurance training, cardiovascular conditioning and training, and other various fitness activities. I hereby affirm that I am in good physical condition and do not suffer from any known disability or condition which would prevent or limit my participation in this exercise program. I acknowledge that my enrollment and subsequent participation is purely voluntary and is in no way mandated. I understand that I am responsible for the care and safety of my minor child during my participation in all Be Well with Beth programming and I understand the risks related to having a minor child in a fitness class. I hereby release Beth Auguste from any liability now or in the future for injury of my minor child. In consideration of my participation in this program, I hereby release Beth Auguste from any claims, demands, and causes of action as a result of my voluntary participation and enrollment. I fully understand that I may injure myself as a result of my enrollment and subsequent participation in this program and I hereby release Beth Auguste from any liability now or in the future for conditions that I may obtain. I hereby release Beth Auguste from any claims that may arise in the future as the result of injury or loss I suffer as the result of negligence by Beth Auguste in the provision of services to me. These conditions may include, but are not limited to, heart attacks, strokes, muscle strains, muscle pulls, muscle tears, broken bones, shin splints, injuries to knees or other joints of the body, injuries to back or neck, injuries to a foot, heat prostration, or any other illness or soreness that I may incur, including death.
In consideration of being permitted to use Be Well with Beth’s facilities, equipment, classes or programs along with my minor child, I further agree to INDEMNIFY AND HOLD HARMLESS Be Well with Beth, which includes any increase in liability insurance premiums incurred by Be Well with Beth as a result of any claim made of loss suffered by me or my minor child, such indemnity to be of and from any nature whatever arising out of or in any way relating to my use of the facility, equipment, classes or programs regardless of whether my minor child or I followed safety policies or received or training from Be Well with Beth.
Participation with a minor child:
I have full knowledge of the nature and extent of the minor child’s risk inherent in the use of the facilities, equipment, classes or programs and am voluntarily assuming all such risks. The minor’s parent or legal guardian understands the minor’s parent or legal guardian will be solely responsible for any loss or damage including death, minor sustains while using the facilities, equipment, classes or programs and by the Waiver and Release the minor’s parent
or guardian is relieving Be Well with Beth and its Employees and Independent Instructors from any and all liability for such loss, damage or death.
I UNDERSTAND THAT I AM FULLY RESPONSIBLE FOR THE ACTIONS OF MY MINOR CHILD AND ASSUME ALL RISKS OF ILLNESS, INJURY, AND LOSS TO THE CHILD AND/OR THE CHILD’S PERSONAL PROPERTY INCLUDING THEFT OF SUCH PROPERTY.
Be Well with Beth periodically takes photographs and/or video for advertising purposes including but not limited to print ads and website. I hereby grant Be Well with Beth permission to use my likeness (or my minor child) in a photograph in any and all of its publications,
including website entries, without payment or any other consideration. I understand and agree that these materials will become the property of Be Well with Beth and will not be returned. I hereby irrevocably authorize Be Well with Beth to edit, alter, copy, exhibit, publish or distribute this photo for purposes of publicizing Be Well with Beth programs or for any other lawful purpose. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my (or my minor child’s) likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph. I hereby hold harmless and release and forever discharge Be Well with Beth from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization. I am 21 years of age and am competent to contract in my own name and on behalf of my minor child. I have read this release before signing below and I fully understand the contents, meaning, and impact of this release.
I HEREBY AFFIRM THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE STATEMENTS, THEIR MEANING, AND THE IMPACT OF THIS RELEASE.
_________________________________ (Participant’s signature) _________________________________ (Witness)