Participant Registration From & Liability Waiver

Participant Registration Form

Please note that you will only need to complete this form once.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Gender
Ethnicity
Emergency Contact Information*

Name

Phone

Contact NameContact Phone
How did you hear about Wellness Within?
For example: Health Care Provider; Family/Friends; Media, Web search; Social Media
Which Services Interest You?
Individual Type*

Cancer Patient/SurvivorFamily/Support/CaregiverVolunteer/Instructor
For Cancer Patients/Survivors Only

Street Address

Street Address Line 2

Cancer TypeDate of Diagnosis

Postal / Zip Code
With which hospital are you associated? (this is for our information only; insurance providers will not be contacted)*
Liability & Photo Release Waiver
Wellness Within is a non-profit mind body medicine wellness center. References to Wellness Within (WW) include the Wellness Within center, its Board, employees, contractors, volunteer workers, agents and assigns.

Please read and sign for any and all WW classes you plan on attending:
In consideration of my participation in the foregoing, the undersigned acknowledge and agree to the following:*

I, my heirs or legal representatives forever release, waive, discharge, and covenant not to sue Wellness Within or any of its staff members for any injury or death caused by their negligence or other acts. My signature below indicates that I have read and freely signed this agreement, which shall take effect as a sealed instrument.I understand that WW is not an agent of, and has no responsibility for any third party which may provide any services including food, lodging, travel, or certain equipment associated with the classes on or off-campus.Despite precautions, accidents may occur. I understand that participation in some of the activities of the WW classes I may be injured, lose or damage personal property, and/or get sick. I agree that my safety is primarily dependent upon my taking proper care of myself. I agree to advise the activity coordinator immediately if I do not believe I can safely continue in the activity.I understand that, from time to time during a movement class, the instructor may physically adjust students’ form when performing movements. If I do not want such physical adjustments, I will so inform the instructor at each class that I attend. I also acknowledge that if I do wish to receive such adjustments, I will so inform the instructor when an adjustment has gone as far as I desire at that time.I understand that if I have bone cancer or brittle bones, I should NOT participate in Wellness Within movement classes.I agree to reduce the risk of injury to myself and/or others by limiting my participation to reflect my personal comfort level, by wearing the proper protection as dictated by the activity, by not wearing anything that would pose a hazard in the pursuit of the activity, and/or by not ingesting or using any substance during the activity which could pose a hazard to myself or others.I understand that unless noted elsewise, staff/ class instructors of Wellness Within are not doctors or physical therapists, and do not practice medicine. If I experience any discomfort or physical reactions, WW suggests that I see my physician. Furthermore, I shall discuss the suitability of activity with my physician and/or health care providers prior to participation in WW classes, as is appropriate.I understand that Pre-Registration is required for all classes.I understand that I must not attend the class if any of the following new or worsening symptoms unrelated to cancer treatments occur within 72 hours of the start of the event: Fever of 100.0 or higher, Chills, Cough or Shortness of Breath, Headache or Body ache, Loss of taste or smell, Sore throat, Runny Nose or Congestion. Diarrhea, VomitingI understand that wearing a face mask is encouraged at Wellness Within but not required per California state guidelines.I will observe the following courteous & mindful attendance etiquette to the best of my ability: punctuality to be respectful of instructor(s) and fellow event attendees; if running late or are unable to attend I will notify Wellness Within as soon as possible by emailing admin@wellnesswithin.org or calling (916) 788-0333.I understand that if I am attending classes online via Zoom, that I will utilize my camera & microphone to the best of my comfortability when participating, as it is a vital factor towards group cohesion. I also understand that participating from a quiet location is encouraged to help support a safe and undisturbed environment for myself and fellow event attendees.I understand the existence of the risk to my health related to my participation to the class that may cause injury or illness such as, but not limited to Influenza, MRSA, or COVID-19 that may lead to paralysis or death.
Therefore, I ASSUME ALL RISKS RELATED TO THE ACTIVITIES including but not limited to:*

Death, injuries of any nature which may be permanent or temporary or contagious diseases or illness from accidents which may occur as a result of participating in an activity or contact with equipment, food, physical surroundings or other persons.Theft or loss of my personal property while in transit or during the WW classes.Natural disaster or other disturbances, and alteration or cancellation of the WW classes due to such causes.
CONSENT TO PHOTOGRAPHY AND/OR RECORDING
I hereby permit Wellness Within and other persons that WW designates, to photograph, make audio or visual recordings and/or create or use images, including web-based images of me in the manner that WW deems appropriate. I give up the right to inspect or approve the final audio/photos or the finished product(s). I further understand that I will not receive any royalties or monetary payment in connection with such audio/photos. If I wish to opt-out of being included in photography and/or recording media, I will notify Wellness Within in writing of my wish to decline.
Signature

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Date Signed

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Date
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Participant Registration Form

Liability & Photo Release Waiver