Please fill out the following health declaration form in order to participate in our activity. Submissions are valid up to 24 hours prior to the activity.
I have volunteered to participate in a fitness program provided to me by Key Therapy Counselor instructors, which may include, but may not be limited to, yoga, pilates, resistance training and aerobic or cardiovascular exercise.
In consideration of the teacher’s agreement to instruct and train, I do here now and forever release and discharge and hereby hold harmless Trainer/Instructor/Key Therapy Counseling and his respective agents, heirs, assigns, contractors, and employees from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected with my participation in this or any exercise program including any injuries resulting there from. THIS WAIVER AND RELEASE OF LIABILITY INCLUDES, WITHOUT LIMITATION, INJURIES WHICH MAY OCCUR AS A RESULT OF (1) EQUIPMENT BELONGING TO TRAINER/TRUMBULL PHYSICAL THERAPY & WELLNESS OR TO MYSELF THAT MAY MALFUNCTION OR BREAK; (2) ANY SLIP, FALL, DROPPING OF EQUIPMENT; (3) AND/OR NEGLIGENT INSTRUCTION OR SUPERVISION; (4) INCLUDES CLASSES IN A PHYSICAL LOCATION LIKE A YOGA STUDIO OR ONLINE LIVE CLASSES OR BY VIDEO, APP OR OTHER DIGITAL PLATFORM.
I have been informed of, understand and am aware that any exercise and/or fitness activities involve a risk of injury, as well as abnormal changes in blood pressure, fainting, and a remote risk of heart attack, stroke, other serious disability, and that I am voluntarily participating in these activities and using equipment with full knowledge, understanding and appreciation of the dangers involved. I hereby agree to expressly assume and accept any and all risks of injury, regardless of severity.
I have been advised that an examination by a physician should be obtained by anyone prior to commencing a fitness and/or exercise program, or initiating a substantial change in the amount of regular physical activity performed. If I have chosen not to obtain a physician’s consent prior to beginning this fitness program with INSTRUCTOR/Trainer/Trumbull Physical Therapy & Wellness, I hereby agree that I am doing so solely at my own risk. In any event, I acknowledge and agree that I assume the risks associated with any and all fitness related activities and/or exercises in which I participate. I ACKNOWLEDGE THAT I HAVE THOROUGHLY READ THIS FORM IN ITS ENTIRETY AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. BY SIGNING THIS DOCUMENT, I AM WAIVING ANY RIGHT I OR MY SUCCESSORS MIGHT HAVE TO BRING A LEGAL ACTION OR ASSERT A CLAIM AGAINST INSTRUCTOR/ TRAINER/TRUMBULL PHYSICAL THERAPY & WELLNESS FOR YOUR NEGLIGENCE OR THAT OF YOUR EMPLOYEES, AGENTS, OR CONTRACTORS.
Your initials attests to reading this entire waiver. If you do not understand any part of this document, it is your ultimate responsibility to ask for clarification prior to signing it.
You have the right to confidentiality and privacy by the group leaders and other group members. Confidentiality within the group setting is a shared responsibility of all members and leaders. While group leader may not disclose any client communications or information except as required by law, group members’ communications are not protected. As such, confidentiality within the group setting is often based on mutual trust and respect.
As a member of this group, I agree to not disclose to anyone outside the group any information that may help to identify another group member. This includes, but is not limited to, names, physical descriptions, biological information, and specifics to the content of interactions with other group members.