REVIBE - WAIVER OF LIABILITY & MEDICAL FORM

WAIVER OF LIABILITY & MEDICAL FORM
Participant Agreement: Including Assumption of Risk, Waiver, and Indemnification Agreement for the activities of Revibe Session, organized by REVIBE EXPERIENCE LLC.

Confidential Waiver of Liability, Medical Questionaire, Agreement of Release.
First Name:*
Last Name:*
Phone Number:*
GENDER

MALEFEMALE
Email:*
Preferred Contact Method (Phone / text / Whatsapp / email:*
Do you speak fluent English? Only Spanish?*
I weight blanks* pounds.
My height is blanks*feet tall.
Date of Birth (if you are under 18 years old, parents must sign waiver)*

MonthDayYear
My session takes place in:

Miami Beach, FloridaSan Clemente, CaliforniaOahu, HawaiiPunta Cana DRCasa de Campo DRTropicalia DRHomestead Cenote, FloridaGran CaymanBonaireBahamas
Emergency contact (and relationship)*

First NameLast Name & relationship
Emergency contact Phone Number*

Area CodePhone Number
Parents Name (only if you are under 18 years old)

First NameLast Name
Parent Phone Number
Participant Signature*

Clear
Parent Signature (if you are under 18 yrs)

Clear
Street Address*
City:*
State:*
Zip*
COUNTRY OF ORIGIN: blanks
If you are staying in a Hotel or Resort, please specify: blanks
Date when your first REVIBE INITIATION SESSION takes place*

MonthDayYear
How did you hear about us?*
Do you have (or ever had) experience with breathwork?*

Yes, I constantly practiceYes, I've done it once or twiceNo, Never tried it and I want to learn
3. Please tell us a little bit more about you and the water. Can you swim 100 meters nonstop without fins?*

Yes I can do it, no problem.I can, but I struggle or have problems doing itI have never done it but I would like to work on it.I can not swim, and I would like to learn.
4. Can you stay afloat without assistance (tread water) for 5 minutes nonstop?*

Yes I can do it, no problem.I have problems doing itI have never done it and would like to work on it.
5. How often do you swim in the ocean?*

DailyOnce a weekAverage once a monthIt has been more than 3 monthsCan't remember, I need to get in the water as soon as possible.
5. What is your Watersports Experience?*

I do NOT know how to swim, but I am interested in breathwork, Ocean Therapy and Cold Exposure (Ice baths).I am learning how to swim and I need tools to gain more confidence in the water.I can swim, but I don't do it often. I have never snorkled without a Life vest.I can swim confidently and practice watersports from time to time. I know how to snorkel but never been deeper than 3 meters ( 10 ft).I am a watersports enthusiast and I feel at home in the water, but I have never practiced freediving.I am a experienced water athlete. Example: Active Surfer, Certified Freediver, Spear fisherman, Long distance Swimmer, Advanced scuba diver, Lifeguard, CPR trained.
Please answer YES or NO
Do you currently have a cold, sinus congestion or any cold related symptoms?

YESNOOther
Do you have (or ever had) ear problems, broken ear drums or severe Chronic sinus?*

yesno
If Yes, please tell us about it.
example: Broken ear drum in diving accident
I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*

yesno
If Yes, What is the medication and what is it for?
example: Broken ear drum in diving accident
I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*

yesno
If Yes, please tell us about it.
example: Broken ear drum in diving accident
I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*

yesno
If Yes, please tell us about it.
example: Broken ear drum in diving accident
I have had stomach or intestine problems, including recent diarrhea.*

yesno
If Yes, please tell us about it.
example: Broken ear drum in diving accident
I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability.*

yesno
If Yes, please tell us about it.
example: Broken ear drum in diving accident
I have had or currently have back, hip or knee problems, hernia, ulcers, or diabetes.*

yesno
if yes, please tell us about it
Please help us provide a more tailored session for you. What sports do you practice?What is your goal for the session? Is there any special information you want to share?
If you want to share your Instagram great, if not no problem, we will always as before posting or tagging you:
@username
I, (client), hereby agree to the following:

1. That I am participating in a training offered by REVIBE EXPERIENCE LLC, during which I will receive information and instruction about health, fitness and wellbeing. I recognize that fitness programs require physical exertion, which may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved.

2. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the program. I represent and warrant that I am physically fit and I have no medical condition, which would prevent my full participation in the program.

3. In consideration of being permitted to participate in the fitness program, I agree to assume full responsibility for any risk, injuries or damages, known or unknown, which I might incur as a result of participating in the program.

4. In further consideration of being permitted to participate in the fitness program “REVIBE EXPERIENCE”, I knowingly, voluntarily, and expressively waive any claim I may have against REVIBE EXPERIENCE LLC, and all members, REVIBE EXPERIENCE Staff, and REVIBE EXPERIENCE advisors, for injury or damages that I may sustain as a result of participating in the REVIBE Experience.

5. I, my heirs, or legal representatives’ forever release, waive, discharge, and covenant not to sue REVIBE EXPERIENCE LLC., or any of its members for any injury or death caused by their negligence or other acts.

6. I understand and give REVIBE EXPERIENCE LLC the right to use any video or images of my fitness training, running, interactions, or any type of training for commercial or promotional use on REVIBE EXPERIENCE LLC Social channels and websites. This waiver is confidential, if you desire not to be filmed or photographed we will respect that 100%.

7. REFUND / CANCELLATION POLICY

Participants who make a deposit (total or fraction) are eligible for a full refund within 7 days of initial payment, as long as there are 2 days or more until the Experience begins. A refund will not be issued if client 2 days before the start of the Experience. Full Payment is due 2 days prior to the Experience. If your session is a Demo, please pay no attention to this paragraph.

8. ASSUMPTION OF THE INHERENT RISKS.

The activity may contain (deep) breathing exercises, (challenging) yoga poses,
conditioning and strength training (increasing heart rates, blood pressure) and exposure to ocean fauna, such as: Jellyfish, Man–o–War, dolphins, sharks, tarpons, manta rays, manatees, crabs, lobster and other sea creatures and/or bacteria. It may also contain exposure (extreme) cold including but not limited to ice baths and/or exposure to cold natural water.

Inherent risks of the activity may include:
- Unexpected, unwanted or undesired results of (deep) breathing exercises, such as loss of consciousness or loss of bodily functions.
- (Physical) reactions of the body due to exposure to (extreme) cold.
- Terrain, surface or subsurface conditions.
- Unpredictable weather changes.
- Accidents during transportation.
- Failure of equipment.
- Errors in judgment by staff or co-participants.
- Accidents during physical exercises and activities, including but not limited to swimming, Apnea exercises in the pool or in the ocean, with or without weights, paddleboarding, yoga.
- Accidents with Marine with animals like Jellyfish of all kinds, barracudas, Sharks, rocks, or any marine animal or element.
Agreement*

I agree to these terms and policies.
Signature:*

Clear
Date:*

DíaMesAño
Date of your REVIBE SESSION

MonthDayYear
Date
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