• Seniors Connect

  • PVCC Seniors Connect Waiver Instructions

    If you participate in any physical activity offered through Seniors Connect, please complete the waiver section.

    Provide:

    • Participant Name
    • Phone Number
    • Emergency Contact Name
    • Emergency Contact Phone Number

    Please read the waiver carefully before signing.

    The waiver explains:

    • Potential risks associated with physical activity
    • Your responsibility to participate safely
    • Release of liability provisions
    • Emergency contact authorization
    • Photo consent options

     

    Submit

     

  • Exercise Participation Waiver and Release of Liability

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Acknowledgement of Risk

  • I understand that participation in exercise, fitness, stretching, walking, balance training, chair exercises, recreational activities, and other physical activities offered through the PVCC Seniors Connect Program involves certain risks, including but not limited to:

    Muscle strains or sprains
    Falls or loss of balance
    Increased heart rate or blood pressure
    Physical discomfort or injury
    Aggravation of existing medical conditions
    I understand that these activities are voluntary and that I may choose not to participate in any activity at any time.

    Health Responsibility
    I confirm that:

    I am responsible for determining whether I am physically able to participate in program activities.
    I will exercise within my own comfort and ability level.
    I will immediately stop any activity if I experience pain, dizziness, shortness of breath, or discomfort.
    I will inform the instructor or volunteer of any concerns related to my participation.
    I understand that PVCC volunteers and instructors are not providing medical advice.
    If I have any health concerns, I understand that it is my responsibility to consult with my physician or healthcare provider before participating.

    Release of Liability
    In consideration of being permitted to participate in activities offered by the Parkland Village Community Centre (PVCC), I hereby release and hold harmless PVCC, its board members, volunteers, instructors, employees, contractors, and representatives from any and all claims, demands, actions, damages, losses, or liabilities arising from or related to my participation in program activities, except where prohibited by law.

    I understand and accept the risks associated with participation and voluntarily assume responsibility for my involvement.

    Emergency Medical Assistance
    In the event of an emergency, I authorize PVCC volunteers or representatives to contact emergency services and my emergency contact if necessary.

    I understand that any medical expenses incurred are my responsibility.

  • Photo Consent - Please select one:*
  • Date
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  • Date
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  • Should be Empty: