Release of Liability - Personalized Fitness For You

WE NEED SOME INFO FROM YOU

Document 2 of 3 – Getting close!

Please complete the below Release of Liability, Indemnity Agreement, and Limited Power of Attorney.

Release of Liability, Indemnity Agreement, and Limited Power of Attorney In consideration of being allowed to participate in the personal fitness training activities and programs of PERSONALIZED FITNESS FOR YOU, LLC and to use its facilities, equipment and services (including specifically online services), in addition to the payment of any fee or charge, I do hereby forever waive, release and discharge PERSONALIZED FITNESS FOR YOU, LLC, DAVID GROUT, AND/OR JOY GROUT and their officers, agents, employees, representatives, executors and all others acting on their behalf from any and all claims or liabilities for injuries or damages to my person and/or property, including those caused by negligent act or omission of any of those mentioned or others acting on their behalf, arising our of or connected with my participation in any activities, programs or services of PERSONALIZED FITNESS FOR YOU, LLC, DAVID GROUT, AND/OR JOY GROUT or the use of any equipment at various sites, including home or office, provided by and/or recommended by PERSONALIZED FITNESS FOR YOU, LLC, DAVID GROUT, AND/OR JOY GROUT.
Initial in the Box Below*
2. I have been informed of, understand and am aware that strength, flexibility and aerobic exercise, including the use of equipment, is potentially hazardous activity. Also, I have been informed of, understand and am aware that fitness activities involve risk of injury, including remote risk of death or serious disability, and I am voluntarily participating in these activities and using equipment and machinery with full knowledge, understanding and appreciation of the dangers involved. I hereby agree to expressly assume and accept any and all risks of injury or death.
Initial in the Box Below*
3. I do hereby further declare myself to be physically sound and suffering from no condition, impairment, disease, infirmity or other illness that would prevent my participation in these activities or use of equipment. Also, I acknowledge that it has been recommended that I have a yearly or more frequent physical examination and consultation with my physician as to physical activity, exercise and use of exercise equipment. Also, I acknowledge that either I have had a physical examination and have been given my physician’s permission to participate or I have decided to participate in the exercise activities, programs and use of equipment without the approval of my physician and do hereby assume all responsibility for my participation in said activities, programs and use of equipment.
Initial in the Box Below*
4. I understand that PERSONALIZED FITNESS FOR YOU, LLC, DAVID GROUT, AND/OR JOY GROUT providing and maintaining an exercise/fitness program for me does not constitute an acknowledgement, representation or indication of my physiological well-being or medical opinion relating thereto.
Initial in the Box Below*
5. I hereby appoint Joy Grout or David Grout each to act alone, or delegate to a person the power to consent on my behalf to all emergency treatment and/or medical care (except elective surgery) determined to be necessary or desirable by my attending physician at the hospital and to serve as my health care representative in the event of my incapability of consenting, as authorized by Indiana Code 16-36-1, and, to this end, and acting in my best interests: to (a) Select, engage and discharge health care providers and facilities; (B) Authorize relief from pain; (C) Grant releases to health care providers and facilities and (D) Give consent to all necessary emergency medical treatment.
Initial in the Box Below*
6. This Power of Attorney shall continue until revoked by the undersigned, or until ________________, 20__, whichever is earlier. Physicians and the hospital’s medical staff may assume and rely upon the fact that this authorization is currently in effect during such period unless notified.
Initial in the Box Below*
7. I certify that photographs or videotape pictures of my image participating in a PERSONALIZED FITNESS FOR YOU, LLC program may be reproduced and utilized in promotional materials for the Fitness Center including online and on social media sites. I certify that for purposes of following up on my experience, PERSONALIZED FITNESS FOR YOU, LLC may release my name to a support fitness entity.
Initial in the Box Below*
8. I understand and certify that my participation in PERSONALIZED FITNESS FOR YOU, LLC and its activities is completely voluntary and I have familiarized myself with the mission, programs and activities in which I will be participating. I understand that PERSONALIZED FITNESS FOR YOU, LLC, DAVID GROUT, AND/OR JOY GROUT cannot insure nor guarantee that the participants, equipment, premises and/or activities will be free of hazards, accidents and/or injuries. I further acknowledge the existence of and understand the rules, regulations and procedures for working out safely and attending the Fitness Center.
Initial in the Box Below*
9. In consideration of PERSONALIZED FITNESS FOR YOU, LLC, DAVID GROUT, AND/OR JOY GROUT accepting and permitting me to view, attend and participate in programs offered, I agree that PERSONALIZED FITNESS FOR YOU, LLC, DAVID GROUT, AND/OR JOY GROUT, their agents, officers, employees, trustees and volunteers will not be liable for any injury, death, damage and/or loss to me and/or anyone making a claim on my behalf, and I further agree to hold harmless, indemnify and defend PERSONALIZED FITNESS FOR YOU, LLC, DAVID GROUT, AND/OR JOY GROUT, their officers, staff, agents, employees, trustees and volunteers for and from any and all liability, claims, causes of actions, losses, injuries, expenses, fees, judgments and/or damages (including specifically reasonable attorneys’ fees and litigation expenses, whether or not suit is filed) arising out of any injury, illness or death to me or property damage during the time of my participation in activities provided or suggested by PERSONALIZED FITNESS FOR YOU, LLC, whether such injury, illness, death, or damage occurs on or off the premises.
Initial in the Box Below*
10. PERSONALIZED FITNESS FOR YOU is not responsible for any at home injuries or accidents from participating in Virtual Training or Classes.
Initial in the Box Below*
11. I am at least eighteen (18) years of age and I am under no mental or legal disability which would prevent me from signing and executing this agreement. I further represent that I have read (or have had read to me) and understand the terms of this agreement.
Initial in the Box Below*
Name*
First Last
Date*
MM slash DD slash YYYY