Wellness Program Application

WELLNESS PROGRAM APPLICATION

The Wellness Center for Hope promotes wellness, healthy living, and overall quality of life in cancer survivors and caregivers by offering access to knowledge and a variety of health-oriented activities that will aid in a healthier cancer journey. Please complete the form to the best of your ability. You are responsible for completing the 3 Step Process for obtaining The Medical Clearance Form. All steps must be complete before activities can begin.
Wellness Policies and Guidelines

Eligibility Criteria

Applicants Must:
- Have a confirmed cancer diagnosis; proof of diagnosis is required
- Live in or receive treatment in our four-county service area
  - Benton
  - Madison
  - Carroll
  - Washington
Program Details

Hope Cancer Resources provides free personal training, group workouts, yoga classes, meditation and nutrition education sessions. All activities are at no cost to the individual.

Wellness Program Policy
- When attending yoga classes, we ask that phones are silenced and that no one walks in more than 10 minutes after class begins.
- When attending a wellness consulation/personal training/nutrition education or other in-person sessions, that the patient calls to reschedule if they are going to be more than 10 minutes late.
- If there are more than two 'no-shows', a discussion will take place between the Trainer and patient and the program will be re-evaluated.
- If at anytime the Trainer feels it is in the best interest of the patient to pause or stop using the Wellness Center, the Trainer has a right to do so.
- Hope Cancer Resources provides services to anyone in our service area with a qualifying cancer diagnosis. Services available to patients are approved or denied on a case-by-case basis. Hope Cancer Resources reserves the right to refuse services at our discretion on factors including but not limited to availability of resources, patient conduct, and responsible engagement of services.
Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
Preferred Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Ethnicity*
Sex assigned at birth*
Primary phone number*
Other phone number
Email address*
example@example.com
Are you the patient or a caregiver?*
Diagnosis-Cancer Type*

BladderBrainBreastCervixColonEsophagusKidneyLeukemiaLiverLungLymphomaMelanomaMyelomaOvaryPancreasProstateRectumSarcomaSkinStomachTongueUterusNone- I am the caregiverOther
Date of Diagnosis

MonthDayYear
Date
Treatment Status

Currently Under TreatmentPost Treatment
Date of Last Treatment- if applicable

MonthDayYear
Date
How do you prefer to be contacted?

By phone callBy emailBy mail
Of the services below, please check all categories that you'd be interested in pursuing through the Wellness Center for Hope.

Nutrition EducationPersonal TrainingWorkout ClassesYogaMeditation Resources
Are you receiving any type of health care treatment or medication that would prevent you from participating in our program?*

YesNo
If YES, please specify
If you do have medical conditions, have you consulted with your physician about participating in this Wellness Program?*

YesNo
Emergency Contact
Name
Phone Number
Relationship
WAIVER AND RELEASE OF LIABILITY

This Waiver and Release of Liability ("Agreement") is entered into by the undersigned, on his or her own behalf, and on behalf of his or her heirs, executors, administrators, assigns, and personal representatives (collectively, “Releasor,” “I,” or “me”) for participation in physical exercise, use of fitness equipment, and other use of the facilities (“Activities”) at The Wellness Center for Hope ("Facility") operated by Hope Cancer Resources, a not-for-profit organization located in Springdale, Arkansas (“Hope Cancer Resources”).

1. Voluntary Participation and Assumption of Risk

I am voluntarily participating in the Activities at the Facility entirely at my own risk, whether supervised or unsupervised. I understand that the Activities involve risks of injury, including but not limited to physical or psychological injury, pain, suffering, illness, temporary or permanent disfigurement, or other injuries, including the risk of death. I understand that these injuries or outcomes may arise from my own or others’ actions or negligence. I understand and freely accept all risks associated with the Activities, both known and unknown, regardless of whether instruction or supervision is provided, and even if arising from the negligence of Hope Cancer Resources or others.

2. Release of Liability

In consideration for being permitted to use the Facility and participate in the Activities, I hereby release and discharge Hope Cancer Resources and its owners, affiliates, officers, directors, employees, agents, attorneys, representatives, predecessors, successors, and assigns (collectively, “Releasees”) from any and all liability, claims, demands, or causes of action that I may have now or in the future for injuries, damages, or losses arising out of or relating to my use of the Facility and/or participation in the Activities.

3. Medical Clearance

I affirm that I am in good physical condition and do not suffer from any medical or other condition which would prevent or limit my participation in the Activities. I understand that it is my responsibility to consult with a physician prior to participating in the Activities.

4. Supervision Disclaimer

I understand that Hope Cancer Resources staff may not always be present or supervising the Activities. I accept full responsibility for my actions related to the Activities and acknowledge that emergency assistance may not be immediately available.

5. Indemnification

I agree to indemnify, defend, and hold harmless Releasees against any and all claims, suits, or actions of any kind whatsoever for liability, damages, compensation, or otherwise, brought as a result of my participation in the Activities, including costs and attorney’s fees.

6. Choice of Law, Entire Agreement, Severability

I agree that this Agreement shall be governed for all purposes by Arkansas law, without regard to any conflict of law principles. This Agreement is the entire agreement between the parties with respect to the subject matter and supersedes any and all previous oral or written promises or agreements. No change, modification, amendment, or addition of or to this Agreement shall be valid unless it is in writing and signed by an authorized representative of all parties. This Agreement is binding upon and ensures to the benefit of the successors, assigns, and legal representatives of the parties. If any provision or portion of this Agreement is found to be illegal, invalid, or unenforceable, the remaining provisions or portions of the Agreement shall remain in full force and effect.
SIGNED AGREEMENT

I have read this Agreement, understand its terms, and sign it freely and voluntarily. I understand that this Agreement affects my legal rights and that by signing it, I am waiving certain legal rights I may have against the Releasees.
Print Name*
Date*

MonthDayYear
Date
Signature*

Clear

WELLNESS PROGRAM APPLICATION

Emergency Contact