Descriptor (Required) Individual with a brain injury Family member/caregiver Professional/Provider Address
(Required) Acknowledgment & Assumption of Risks (Required)
The undersigned, being an individual or individual’s legal guardian (collectively, “Athlete”) acknowledges and understands the significant risk of injury, paralysis or death from fitness activities. Athlete also understands that physical conditions, such as high cholesterol, heart conditions, frequent pain in the chest, joints or bones, high blood pressure, frequent light-headed or dizziness, and other physical conditions heighten the risk of injury. Athlete also acknowledges that any classes, instruction, or training will be executed by the Athlete at a place, in a manner and using equipment or facilities of Athlete’s own choosing, without in-person supervision of Staying Driven. The Athlete agrees either to (1) consult a physician and/or other health or fitness professional before, throughout, and after using Staying Driven’s services, or (2) to assume the risk of using Staying Driven’s services without consulting such professionals, understanding that doing so increases the risk of injury.
Release and Waiver of Liability and Indemnity
Athlete understands the risks described above. Athlete knowingly and voluntarily releases and agrees to indemnify, defend protect and hold harmless Staying Driven, its officers, directors, managers, members, shareholders, employees, agents, independent contractors, successors, assigns, and instructors, from any and all liability to Athlete and Athlete’s, family (by blood, marriage or legal status), relatives personal representatives, assigns and heirs for any damages, claims (including but not limited to personal injury or loss of consortium) or demands arising out of Staying Driven’s services pursuant to athlete’s membership and Athlete’s participation in classes, instruction or training as part of Staying Driven’s services, EVEN WHERE INJURY OCCURS, WHOLLY OR PARTLY, AS A RESULT OF CONSULTANT’S NEGLIGENCE. Athlete expressly agrees that the foregoing waiver is intended to be as broad and inclusive as permitted by Arizona law; and that if any portion of the waiver is held invalid, the balance is to be given full force and effect. Athlete agrees that if he/she begins to experience symptoms or signs of health issues either during classes, instruction or training, Athlete will stop the activity and seek necessary medical or health advice from a health professional.
Jurisdiction and Venue for Claims
Athlete agrees that the Federal and State Courts in the State of Arizona, United States of America, shall have sole and exclusive jurisdiction over any claims
and persons bringing such claims against Staying Driven which arise out of Athlete’s membership or participation in Staying Driven’s services. Venue shall be proper in Arizona and Arizona law shall apply to all legal disputes and claims, without regard to conflict of law principles. By signing below, Athlete acknowledges, assumes, releases, waives, indemnifies and submits to jurisdiction as described herein. I understand the risks. Waiver and Release of Liability (Required)
I am voluntarily participating in the class being taught by Resources for Seniors using the Zoom Platform. This is an exercise/fitness program conducted by certified instructor of the Northern Wake or Eastern Wake Senior Centers. This class is being provided on the Zoom platform. I will be participating in a location deemed safe by me to participate in this class and take full responsibility for my well-being.
During my participation in this class, I acknowledge that Resources for Seniors and the instructor are not liable for any risks, injuries, or damages which I might incur because of participating in the program.
I recognize that the program I select may requires physical exertion that may be strenuous at times and may cause physical injury. I am fully aware of the risks and hazards involved. Senior Center participants interested in taking any advanced level class must be screened by Senior Center staff and agree to indemnify the volunteer instructor in writing, before taking the first class.
I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the above-mentioned program. I represent and warrant that I have no medical condition that would prevent my participation in the program.
I agree to assume full responsibility for any risks, injuries, or damage, know or unknown, which I might incur because of participating in this trial program.
I have read the above waiver and release of liability and fully understand it contents. I voluntarily agree to the terms and conditions stated above. I understand the risks. Why are you interested in taking the class/program? (Required)
If unsure, what are your short-term goals? What would you like to improve or build upon?
Are you joining as a group or individual? (Required) Caregiver Name
Is the person attending the program their own legal guardian? (Required) Legal Guardian Name (Required)
Legal Guardian Address
(Required) I grant Hinds' Feet Farm & BIANC the right to use my (please check all that apply) Online Media Consent Form (Required)
I authorize Hinds Feet Farm (HFF), its assigns and transferees to copyright, use and publish this information about me in print and/or electronically. I agree that HFF may use such information about me with or without my name and for any lawful purpose, including but not limited to such purposes as publicity, illustration, advertising, social media, and Web content. This consent also includes the right to make such changes, fictionalizations and/or creative choices as HFF may decide in its sole discrtion. I agree not to bring any action or claim(s) against HFF and its governing board, directors, officers, empoloyees, volunteers and/or agents now or in the future based on the use and dipiction of my information. I understand that I may revoke this release in writing if I wish for my information to be exclused from future media uses. I understand that I cannot revoke a release of my information for which I have given prior consent for media that is already existing and/or publishes.
· I am 18 years old or older and a resident of North Carolina.
· I have a traumatic or acquired brain injury.
· Hinds’ Feet Farm has permission to contact and share my information with the emergency contact person I have provided as well as my caregiver as needed.
· I agree to participate in virtual programming using the Zoom platform, which is not considered to be a secure or confidential online platform. I understand that virtual programming may be recorded.
· I understand that physical activity, by its very nature, carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. Hinds’ Feet Farm’s programs provide physical activities including but not limited to yoga, hiking, health and nature walks, sports activities, working out at the local gym, various group exercise classes, etc. The specific risks vary from one activity to another, but the risks range from 1) minor injuries such as scratches, bruises, and sprains; 2) major injuries such as eye injury, back injury, heart attacks, and concussions; and 3) catastrophic injuries including paralysis and death. I understand that physical activities carry certain inherent risks, and I hereby assert that my participation is voluntary and that I knowingly assume all risks. I release HFF from any and all liability arising out of my participation in any physical activities and hereby waive my rights herein to assert any action or claim(s) against HFF and its governing board, directors, officers, employees, volunteers, community instructors, and/or agents.
· I agree to follow the rules of the Hinds’ Feet Farm virtual day program and understand that failure to follow program rules may result in my suspension or expulsion from the program:
o Respect the views and opinions expressed by others in the group.
o No use of illegal drugs, tobacco or alcohol during program activities.
o No cursing or suggestive language.
o Only the enrolled member and a caregiver are allowed in the virtual activity.
o Must be fully dressed at all times.
o May not threaten to harm others.
o Keep information shared by others in the virtual activity confidential.
o Have a contact person for us to reach out to in case of emergency or concerning behavior.
o Hinds’ Feet Farm staff reserve the right to remove you from the virtual activity due to disruptive or threatening behavior.
o Video must be left on at all times while participating in virtual programming.
I will keep all information confidential that is discussed as part of Hinds’ Feet Farm’s programs within a group setting. I agree to follow the program rules.