Healthcare Fitness Waiver

HEALTHCARE FITNESS WAIVER

Participant Information

Emergency Contact

Insurance Information

Medical History

Planned Activities & Physician Clearance

I certify that, to the best of my knowledge, I am physically fit and capable of participating in the activities described above. I understand that if I have any concerns regarding my ability to participate safely, I should obtain medical clearance from a licensed physician prior to participation.

Physician clearance has been obtained for participation.

Risk Disclosure, Release and Indemnification

I acknowledge that participation in physical activity, exercise, and related programs involves inherent risks, including but not limited to musculoskeletal injuries, cardiac events, heat-related illness, and other physical or mental injury. I freely accept and fully assume all such risks, both known and unknown, even if arising from the negligence of the released parties, and assume full responsibility for my participation.

In consideration of being permitted to participate, I, on behalf of myself, my heirs, assigns, personal representatives and next of kin, hereby release, waive, discharge and covenant not to sue the facility, its parent companies, affiliates, directors, officers, employees, contractors, volunteers and agents (collectively, the Released Parties) from liability for any and all claims, demands, actions, causes of action, costs and expenses, including attorneys' fees, arising out of or related to any loss, damage, injury or death that may be sustained by me while participating, whether caused by the negligence of the Released Parties or otherwise.

I further agree to indemnify, defend and hold harmless the Released Parties against any and all claims, liabilities, losses, damages or expenses (including reasonable attorneys' fees) arising from my negligent, reckless or intentional acts or omissions while participating.

Emergency Medical Treatment & Financial Responsibility

In the event of an emergency, I authorize the Released Parties to arrange for medical care and transportation to an appropriate medical facility if necessary. I acknowledge and agree that I am financially responsible for all costs associated with such care and transportation, including but not limited to ambulance, emergency, hospital, and physician fees, and that the Released Parties are not responsible for such costs.

HIPAA / Privacy Acknowledgment

I acknowledge that medical and personal information collected in connection with participation may constitute protected health information. I authorize the facility to use and disclose my protected health information for the purposes of treatment, payment, and healthcare operations as necessary to administer services, process claims, and coordinate care. I understand that my information will be handled in accordance with applicable privacy laws.

I acknowledge receipt of the facility's privacy practices and consent to the use and disclosure described above.

Certification and Authorization

I certify that the medical information I have provided on this form is true and accurate to the best of my knowledge. I understand that provision of false information may endanger my health and may void this waiver. I understand that I may withdraw consent for future uses of my protected health information except to the extent that action has already been taken in reliance on this authorization.

This authorization shall remain in effect until , unless revoked earlier in writing. Revocation will not affect disclosures or actions taken prior to revocation.

I understand that I have the right to withdraw from participation at any time. I further acknowledge that I have read this document in its entirety, understand its terms, and sign it voluntarily of my own free will.

Acknowledgments

I have read and understand the Risk Disclosure, Release and Indemnification clauses above.

I authorize emergency medical treatment as described above.

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