Mindset Reps @ OTAC Summer Session Registration Form

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Mindset Reps (and FYR) Exercise Release Waiver - Participating Gyms Including: Old Town Athletic Club, CrossFit 970 and OTAC CrossFit, KODA Ironview, Official Fitness and offsite activities. Mindset Reps and FYR Mindset Reps, involves weightlifting, sprinting and gymnastics all of which subject participants to potential injury that is inherent in the nature of the activities. By agreeing to workout at Mindset Reps you agree that you are voluntarily participating in these activities and use of these facilities and premises and assume all risks of injury, illness, or death or loss of personal property. This waiver and release of liability includes, without limitation, all injuries which may occur as a result of, (a) your use of all amenities and equipment in the facility and your participation in any activity, class, program, personal training or instruction, (b) the sudden and unforeseen malfunctioning of any equipment (c), the actions of fellow participants in the club while taking part in any activity, class, program, personal training or instruction (d) our instruction, training, supervision, or dietary recommendations, and (e) your slipping and/or falling while in the club, or on the club premises, including adjacent sidewalks and parking areas. Because exercise can be strenuous and subject participants to risk of serious injury, Mindset Reps urges you to obtain a physical examination from a doctor before using any exercise equipment or participating in any exercise activity. You (each member, guest, and all participating family members) agree that if you engage in any physical exercise or activity, or use any Mindset Reps amenity on the premises or off-premises including any sponsored club event, you do so entirely at your own risk. Any recommendation for changes in diet including the use of food supplements, weight reduction and or body building enhancement products are entirely your responsibility and you should consult a physician prior to undergoing any changes. You expressly agree to release and discharge Mindset Reps, and all affiliates, employees, agents, representatives, successors, or assigns, from any and all claims or causes of action and you agree to voluntarily give up or waive any right that you may otherwise have to bring a legal action against Mindset Reps for personal injury or property damage. To the extent that statute or case law does not prohibit releases for negligence, this release is also for negligence on the part of Mindset Reps, its agents, and employees. If any portion of this release from liability shall be deemed by a Court of competent jurisdiction to be invalid, then the remainder of this release from liability shall remain in full force and effect and the offending provision or provisions severed here from. By signing this release, I acknowledge that I understand its content and that this release cannot be modified orally. You acknowledge that you have carefully read this "waiver and release" and fully understand that it is a release of liability.

MINDSET REPS Privacy and Consent. 1136 E Stuart St Suite 4204 FORT COLLINS, CO 80525 - Informed Consent for Psychotherapy. - Mindset Reps specializes in counseling, mental health education, peer support and fitness. Mindset Reps office is located at 1136 E Stuart Street Suite 4-204, Fort Collins, Co 80525. Mindset Reps also operates out of community spaces. General Information. - You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. We cannot promise that your behavior or circumstance will change. We can promise to support you and do our very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself. Confidentiality - The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below: If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm. If a client threatens grave bodily harm or death to another person. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses. Suspected neglect of the parties named in items #3 and # 4. If a court of law issues a legitimate subpoena for information stated on the subpoena. If a client is in therapy or being treated by order of a court of law, or if the information is obtained for the purpose of rendering an expert’s report to an attorney. Please note that many of our sessions are in community spaces and cannot guarantee that attendance is completely confidential. Occasionally clinicians may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name. - Group Counseling: You have a right to confidentiality from group members and leaders. The responsibility of privacy in a group is a shared process. Group leaders may not disclose any information within the group except as provided by law but group members’ communication is not protected by law. Group member confidentiality is important and is held through group trust and respect. As a member of a group, we ask that you agree by signing this waiver that you will not disclose any information shared within the group to anyone outside the group as well as any identifying factors of any group members. I understand groups may be held in public places such as parks or recreation centers which does not guarantee our ability to keep your attendance confidential. I acknowledge that group counseling sessions may have volunteers, mentors guest/substitute therapists or experts. All persons that attend the group will be held to the same confidentiality standards. Per ACA Guidelines and Colorado state law, I understand that my therapy with Mindset Reps will automatically terminate at the end of every calendar year. If I choose to continue receiving behavioral health services from Mindset Reps I will be required to sign a new Disclosure Statement and Policies document to continue my behavioral healthcare. Clients RightsThe practice of licensed and unlicensed psychotherapist is regulated by the Colorado Department of Regulatory Agencies. Any questions, concerns or complaints regarding the practice of mental health can be directed to The Department of Regulatory Agencies, Mental Health Section at 1560 Broadway, Suite 1350, Denver, CO 80202, (303) 849-7766 - BY SIGNING THE BOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

FYR Mindset Reps Media Release Form

I consent to the unrestricted use, by Forging Youth Resilience; Mindset Reps, LLC) (and those acting with its permission and authority), of any and all media taken, in whole or in part, unlimited use, for all purposes in any form or medium, including, without limitation, its use through or on any electronic media, including the Internet.
I waive any right to inspect or approve the finished product or products or the advertising copy or printed matter that may be used with the finished media.
Further, I relinquish all rights, titles and interest I may have in the finished media, negative(s) and reproduction to any responsible business firm or publication. It is understood that Forging Youth Resilience Mindset Reps retains copyright of media at all times under the express understanding and agreement that Forging Youth Resilience shall have exclusive reproduction rights to the media.
I hereby release Forging Youth Resilience from any and all claims in connection with the media, including any and all claims of libel.

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Youth Resilience Mindset Reps is piloting a program to measure the impact our programs have on youth participants' physical and mental health. This will entail an anonymous pre and post written assessment and fitness benchmark which will be reviewed by researchers at the end of every 12 week period. No names will be released. Please sign the box below if you (your child) consents to participate in this program.