Informed Consent and Release of
Liability
Client’s Name:
______________________________________________________
In consideration of being
allowed to participate in the activities and programs conducted by The 221st
BSB Sports & Fitness Branch,
Community Recreation Division (CRD), The Directories of Community
Activities (DCA), the Department of Defense (DOD), the United States
Government, and as an endorsement to the Morale, Welfare and Recreation Fund
(MWR), and to use its facilities,
equipment, and machinery in addition to the payment of any fee or charge, I do
hereby waive, release, and forever discharge it and it’s officers, agents,
employees, representatives, executors, and all others involved from any and all
responsibilities or liability for injuries or damages resulting from my
participation in any activities or my use of equipment or machinery in any way
associated with the above mentioned organizations, or arising out of my
participation in any activities of the said organization. I do also hereby release all of those
mentioned and any others acting upon their behalf from any responsibility or
liability for any injury or damage to myself, including those caused by the
negligent act or omission of any of those mentioned or others acting on their
behalf or in any way arising out of or connected with my participation in any
activities of The 221st BSB Sports & Fitness Branch, CRD/DCA,
DOD, and the United States Government, or the use of any equipment of the above
mentioned organizations.
(Please Initial _______)
I have volunteered to undergo
a complete fitness assessment and/or participate in an exercise program and
understand and am aware that strength, flexibility, and aerobic exercise,
including the use of equipment is a potentially
hazardous activity. I also understand
that fitness activities involve risk of injury and even death and that I am
voluntarily participating in these activities and using exercise equipment and
machinery with knowledge of the dangers involved. I hereby agree to expressly assume and
accept any and all risks of injury or death. (Please initial______)
I do hereby declare myself to
be physically sound and suffering from no condition, impairment, disease,
infirmity, or other illness that would prevent my participation in any of the
activities and programs of the 221st BSB Sports & Fitness or use
of equipment or machinery except as hereinafter stated. I do herby acknowledge that I have been
informed of the need for a physician’s approval for my participation in an
exercise/fitness activity or in the use of exercise equipment and
machinery. I also 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 and training equipment so that I might have recommendations
concerning these fitness activities and equipment use. I acknowledge that I have either had a
physical examination and have been given any physician’s permission to
participate, or that I have decided to participate in activity and/or use of
equipment and machinery without the approval of my physician and do herby
assume all responsibility for my participation and activities, and utilization
of equipment and machinery in my activities. (Please initial______)
I further understand that
activities, programs, and services offered the 221st BSB Sports
& Fitness are sometimes conducted by personnel who may not be licensed,
certified, or registered instructors or professionals. I accept the fact that the skills and
competencies of some employees and/or volunteers will vary according to their
training and experience and that no claim is made to offer assessment or
treatment of any mental or physical disease or condition by those who are not
dully licensed, certified, or registered and herein employed to provide such
professionals services.
I have read this form
carefully, and I fully understand the nature of the activities. I consent to participate in these tests and/or
exercise programming. I am aware that
this is a release of liability, and a contract between myself
and the Sports & Fitness, CRD, DCA, DOD, and the United States Government,
and sign it of my own free will.
Signature______________________________________
Date: ____________________
Witness________________________________________
Date: ___________________
………………………………………………………………………………………………
Cancellation Policy
You have chosen to
participate in our personal training program.
This is a professional program and as such, we ask that you be
considerate of others’ time. Not only
that, but we want to see you succeed in your program and that requires
consistency and dedication. If you are
unable to make an appointment, you are required to give 24 hours notice to the
personal trainer or fitness coordinator.
If cancellation is made less than 24 hours in advance, the appointment
will be charged as a “used” session except under outstanding circumstances,
such as illness. All “no-shows” will be
charged as a used session.
By signing below, you agree
to the terms of the above cancellation policy.
Participant______________________________ Witness_______________________