Waiver & Release Form – Empowered Performance

Waiver and Release

Please read carefully and type your name where indicated to confirm your understanding and agreement.

I have volunteered to participate in a fitness program provided to me by Stephanie Thompson ("Trainer", and "Service Provider"), which may include, but not be limited to, resistance training and aerobic or cardiovascular exercise, rehabilitative exercise, and mobility or stability training.

In consideration of Trainer’s agreement to instruct, coach and train me, I do here now and forever release and discharge and hereby hold harmless the Trainer and her 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 therefrom.

This waiver and release of liability includes, without limitation, injuries which may occur as a result of (1) equipment belonging to trainer or to myself that may malfunction or break; (2) any slip, fall, dropping of equipment; (3) and/or negligent instruction or supervision.

*Type your name to agree

*Email

Assumption of Risk

I have been informed of, understand and am aware that any exercise program, whether or not requiring the use of exercise equipment, is a potentially hazardous activity.

I also 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 or death, and that 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, regardless of severity, or death.

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Medical Release

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 Trainer, 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.

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CONSENT TO USE ELECTRONIC COMMUNICATIONS TO PROVIDE TELEHEALTH SERVICES

I am aware of the following:

1. Risks of using electronic communication

While the Service Provider will use reasonable means to protect the security and confidentiality of information sent and received using electronic communications, because of the risks outlined below, the Service Provider cannot guarantee the security and confidentiality of electronic communications:

 Use of electronic communications to discuss sensitive information can increase the risk of such information being disclosed to third parties.

 Despite reasonable efforts to protect the privacy and security of electronic communication, it is not possible to completely secure the information.

 Employers and online services may have a legal right to inspect and keep electronic communications that pass through their system.

 Electronic communications can introduce malware into a computer system, and potentially damage or disrupt the computer, networks, andsecurity settings.

 Electronic communications are subject to disruptions beyond the control of the Service Provider that may prevent the Service Provider from being able to provide services

 Electronic communications can be forwarded, intercepted, circulated, stored, or even changed without the knowledge or permission of the Service Provider or the patient.

 Even after the sender and recipient have deleted copies of electronic communications, back-up copies may exist on a computer system.

 Electronic communications may be disclosed in accordance with a duty to report or a court order.

 Videoconferencing using no cost, publicly available services may be more open to interception than other forms of videoconferencing

 There may be limitations in the services that can be provided through electronic communications, dependent on the means of electronic communications being utilized

 Email, text messages, and instant messages can more easily be misdirected, resulting in increased risk of being received by unintended and unknown recipients.

 Email, text messages, and instant messages can be easier to falsify than handwritten or signed hard copies. It is not feasible to verify the true identity of the sender, or to ensure that only the recipient can read the message once it has been sent.

2. Conditions of Using Electronic Communications

 While the Service Provider will endeavour to review electronic communications in a timely manner, the Service Provider cannot provide a timeline as to when communications will be reviewed and responded to. Electronic communications will not and should be used for medical emergencies or other time-sensitive matters.

 Electronic communication may not be an appropriate substitute for some services that the Service Provider offers.

 Electronic communications may be copied or recorded in full or in part and made part of your clinical chart. Other individuals authorized to access your clinical chart, such as staff and billing personnel, may have access to those communications.

 The Service Provider may forward electronic communications to staff and those involved in the delivery and administration of your care. The Service Provider will not forward electronic communications to third parties, including family members, without your prior written consent, except as authorized or required by law.

 Prior to the commencement of the provision of services by the Service Provider through electronic communications, the Service Provider and the patient will establish an emergency protocol to address the following:

o Steps to be followed in the event of a technical issue that causes a disruption in the services that are being provided by the Service Provider; and

o Steps to be followed in the event of a medical emergency that occurs during the provision of services.

 The Service Provider is not responsible for information loss due to technical failures associated with your software or internet service provider.

 The Patient will inform the Service Provider of any changes in the patient’s email address, mobile phone number, or other account information necessary to communicate electronically.

 The Patient will ensure the Service Provider is aware when they receive an electronic communication from the Service Provider, such as by a reply message or allowing “read receipts” to be sent.

 The Patient will take precautions to preserve the confidentiality of electronic communications, such as using screen savers and safeguarding computer passwords.

 If the Patient no longer consents to the use of electronic communications by the Service Provider, then the Patient will provide notice of the withdrawal of consent by email or other written communication.

Acknowledgement and Agreement

I acknowledge that I have read and fully understand the risks, limitations, conditions of use, and instructions for use of the selected electronic communications as described above.

I understand and accept the risks outlined above to this consent form, associated with the use of the electronic communications with the Service Provider and the Service Provider’s staff.

I consent to the conditions and will follow the instructions outlined above, as well as any other conditions that the Service Provider may impose regarding electronic communications with patients.

I acknowledge and agree to communicate with the Service Provider or the Service Provider’s staff using these electronic communications with a full understanding of the risks in doing so.

I confirm that any questions that I had regarding the provision of healthcare services through electronic communications have been answered by the Service Provider.

*I Consent

Yes

No

*Type your name to consent

*Sign to Consent

Media Consent

I hereby authorize any images or video footage taken of myself, in whole or in part, individually or in conjunction with other images and video footage, to be displayed on the Markville Fitness, Allcore PT Rentals, emPOWERed performance, and other official channels, and to be used for media purposes including promotional presentations and marketing campaigns. I also authorize use of any media material created by myself within the context of my participation with Empowered Performance.

I waive rights to privacy and compensation, which I may have in connection with such use of my name and likeness, including rights to written copy that may be created in connection with video production, editing and promotion therewith.

*I Consent

Yes

No

*Type your name to consent

*Sign to Consent

Final Confirmation

I ACKNOWLEDGE THAT I HAVE THOROUGHLY READ THIS AGREEMENT 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 TRAINER FOR YOUR NEGLIGENCE OR THAT OF YOUR EMPLOYEES, AGENTS, OR CONTRACTORS.

This form is an important legal document that explains the risks you are assuming by beginning an exercise program. It is critical that you have read and understand this document completely. If you do not understand any part of this document, it is your ultimate responsibility to ask for clarification prior to signing it.

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Waiver and Release

Assumption of Risk

Medical Release

CONSENT TO USE ELECTRONIC COMMUNICATIONS TO PROVIDE TELEHEALTH SERVICES

Media Consent

Final Confirmation