In consideration of the risk of injury while participating in Assisted Stretch Therapy, and as consideration for the right to participate in the Services, I hereby, for myself, my heirs, executors, administrators, assigns, or personal representatives, knowingly and voluntarily enter into this waiver and release of liability and hereby waive any and all rights, claims or causes of action of any kind whatsoever arising out of my participation in the Services, and do hereby release and forever discharge Coastal Spirit Wellness LLC, 3044 Constellation Dr. Melbourne, FL 32940 and its affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns, for any physical or psychological injury, including but not limited to illness, and economic or emotional loss, that I may suffer as a direct result of my participation in the aforementioned Services, including traveling to and from an event related to these services and health conditions of and relating to a communicable-disease.
I AM VOLUNTARILY PARTICIPATING IN ASSISTED STRETCH THERAPY, PERSONAL TRAINING, YOGA, SOUND THERAPY, MEDITATION, BREATHWORK, AND WELLNESS COACHING. I AM PARTICIPATING IN THE SERVICES ENTIRELY AT MY OWN RISK. I AM AWARE OF THE RISKS ASSOCIATED WITH TRAVELING TO AND FROM AS WELL AS PARTICIPATING IN THESE SERVICES, WHICH MAY INCLUDE, BUT ARE NOT LIMITED TO, PHYSICAL OR PSYCHOLOGICAL INJURY, PAIN, SUFFERING, ILLNESS, AND ECONOMIC OR EMOTIONAL LOSS. I UNDERSTAND THAT THESE INJURIES OR OUTCOMES MAY ARISE FROM MY OWN OR OTHERS' NEGLIGENCE, CONDITIONS RELATED TO TRAVEL, OR THE CONDITION OF THE SERVICES LOCATION(S). NONETHELESS, I ASSUME ALL RELATED RISKS, BOTH KNOWN OR UNKNOWN TO ME, OF MY PARTICIPATION IN THIS ACTIVITY, INCLUDING TRAVEL TO, FROM AND DURING THIS ACTIVITY.
I agree to indemnify and hold harmless Coastal Spirit Wellness LLC against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney's fees and any related costs, if litigation arises pursuant to any claims made by me or by anyone else acting on my behalf. If Coastal Spirit Wellness LLC incurs any of these types of expenses, I agree to reimburse Coastal Spirit Wellness LLC.
I acknowledge that Coastal Spirit Wellness LLC and its directors, officers, volunteers, representatives and agents are
not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Coastal Spirit Wellness LLC.
Conspicuous Consent: Assisted stretch therapy includes an introductory assesment about a clients goals, fitness level, stretch experience, tightness, mobility, flexibility, conditions, pain, comfort level, injuries, surgeries, restrictions, concerns, hydration, nutrition, and any areas to avoid or focus on. A certified practitioner will make physical contact and move or stabilize a client's limbs and body using their our own body weight and gravity while you completely relax or gently help with the movement. The certified stretch practitioner then creates a custom routine stretch experience for progressive results in mobility, flexibility, mind body connection, and over all wellness. Proprioceptive Neuromuscular Facilitation (PNF) method is incorperated with our services that includes activation or flection of a targeted area of muscle/s while in a stretched position to enhance strength & mobility of and around joints, tendons, ligaments, fascia, and muscles in general. Comminucation is the responsibility of the client recieving stretch services if they are to feel pain or discomfort.
General areas of contact are head, neck, arms, hands, abdomin (front & back), hips, glutes, legs, and feet.
Services are not medical treatments or rehabilitation.
I ACKNOWLEDGE THAT I CAN DECLINE ANY TECHNIQUE, BODY AREA, OR DEGREE OF PRESSURE ANYTIME DURING SERVICES.
I ACKNOWLEDGE THAT IF ASKED, THE PRACTITIONER WILL STOP OR MODIFY A TECHNIQUE WHEN REQUESTED.
I ACKNOWLEDGE THAT THIS SERVICE INVOLVES A TEST OF MY PHYSICAL LIMITS.
I ACKNOWLEDGE THAT I AM RESPONSIBLE FOR COMMUNICATING MY PHYSICAL LIMITS CLEARLY AND IN A TIMELY MANNER DURNING SERVICES.
I ACKNOWLEDGE THAT CONSENT CAN BE WITHDRAWN AT ANY TIME, INCLUDING DURING A SERVICE.
I ACKNOWLEDGE THAT I HAD THE OPPOURTUNITY TO ASK QUESTIONS BEFORE SERVICES.
I ACKNOWLEDGE THAT I HAVE CAREFULLY READ THIS "WAIVER AND RELEASE" AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. I EXPRESSLY AGREE TO RELEASE AND DISCHARGE Coastal Spirit Wellness LLC AND ALL OF ITS AFFILIATES, MANAGERS, MEMBERS, AGENTS, ATTORNEYS, STAFF, VOLUNTEERS, HEIRS, REPRESENTATIVES, PREDECESSORS, SUCCESSORS AND ASSIGNS, FROM ANY AND ALL CLAIMS OR CAUSES OF ACTION AND I AGREE TO VOLUNTARILY GIVE UP OR WAIVE ANY RIGHT THAT I OTHERWISE HAVE TO BRING A LEGAL ACTION AGAINST Coastal Spirit Wellness LLC FOR PERSONAL INJURY OR PROPERTY DAMAGE.
Principle risks of assisted stretch therapy: Overstretching and Tissue Damage, Muscle Injury or Rupture, Tendon, Ligament, Joint, or Nerve Injury, Aggravation of Underlying Conditions, Nerve Compression or Irritation, Temporary Soreness, Bruising, Cramping, Dizziness, Light-headedness, Loss of Balance, Joint Dislocation, Fracture particularly with osteoporosis, Instability, Circulatory, or Neurological complications in susceptible clients.
To the extent that statute or case law does not prohibit releases for negligence, this release is also for negligence on the part of Coastal Spirit Wellness LLC, its agents, and employees.
In the event that I should require medical care, treatment, or emergency assistance, I agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.
In the event that any damage to equipment or facilities occurs as a result of my willful actions, neglect or recklessness, I acknowledge and agree to be held liable for any and all costs associated with any actions of neglect or recklessness. This Agreement was entered into at arm's-length, without duress or coercion, and is to be interpreted as an agreement between two parties of equal bargaining strength. Both the Participant, as named above, and Coastal Spirit Wellness LLC agree that this Agreement is clear and unambiguous as to its terms, and that no other evidence will be used or admitted to alter or explain the terms of this Agreement, but that it will be interpreted based on the language in accordance with the purposes for which it is entered into.
I confirm that the information provided is complete and accurate, and changes will be disclosed before later sessions.
I confirm I will immediately report pain, numbness, tingling, dizziness, shortness of breath, or any unusual symptoms directly to the stretch practitioner as it is happening.
In the event of an emergency, I give permission to Coastal Spirit Wellness LLC to call emergency services. When the client cannot consent, Coastal Spirit Wellness is to obtain reasonably necessary emergency care.
I confirm and understand the services offered are not a medical diagnosis, physical therapy, chiropractic adjustment, massage, or a substitute for care from a licensed healthcare professional.
I confirm I will obtain medical clearance before services if requested.
Health Information Privacy and HIPAA Compliance
(a) Scope. In providing stretch therapy services, the Provider may collect information about the Client’s health history, injuries, physical limitations, treatment goals, and services received (“Health Information”). The Provider will protect Health Information as described in this Section. To the extent the Provider is a covered entity or business associate under the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations (“HIPAA”), the Provider will also comply with the HIPAA requirements applicable to its role. This Agreement does not represent that the Provider is a HIPAA covered entity or business associate merely because it collects Health Information.
(b) Use and Disclosure. The Provider will use or disclose Health Information only as reasonably necessary to provide and coordinate services, process payment, conduct legitimate business operations, comply with legal obligations, or as otherwise permitted by this Section. Where HIPAA applies, each use or disclosure must be permitted or required by HIPAA, and the Provider will apply the minimum necessary standard when required. Where HIPAA does not apply, the Provider will limit uses and disclosures to information reasonably necessary for the relevant purpose. The Provider will not sell Health Information or use or disclose it for marketing without the Client’s separate written authorization where required by law. Signing this Agreement does not constitute a HIPAA authorization.
(c) Safeguards and Service Providers. The Provider will maintain reasonable administrative, physical, and technical safeguards designed to protect Health Information against unauthorized access, use, disclosure, alteration, or destruction. Access will be limited to personnel and service providers who need the information for authorized purposes and are subject to appropriate confidentiality obligations. Where HIPAA requires a business associate agreement, the Provider will enter into that agreement before permitting the business associate to access protected health information. This Section does not replace any required business associate agreement.
(d) Client Rights and Privacy Notices. If the Provider is a HIPAA covered entity required to provide a Notice of Privacy Practices, the Provider will furnish that notice and honor the Client’s rights to access and obtain copies of protected health information, request amendments and restrictions, request confidential communications, and receive an accounting of disclosures, to the extent required by HIPAA. If the Provider acts as a business associate, it will assist the relevant covered entity in responding to those requests as required by HIPAA and its business associate agreement. The Client may submit privacy inquiries or complaints to Candice Vermillion and Stefan Massie at MotivatedMovements@CoastalSpiritWellness.com - 3044 Constellation Dr. Melbourne, FL 32940. The Provider will not retaliate against the Client for exercising privacy rights or submitting a privacy complaint.
(e) Security Incidents and Breach Notification. The Provider will promptly investigate suspected unauthorized access to, use of, or disclosure of Health Information and take reasonable steps to contain the incident and mitigate harm. If an incident requires notification under HIPAA or another health-information or data-breach law, the Provider will provide the required notices to the Client, the relevant covered entity, regulators, and other recipients, as appropriate, within the required deadlines. When HIPAA requires notice to an affected individual, the Provider will provide notice without unreasonable delay and no later than 60 calendar days after discovery, subject to any legally permitted delay. Any shorter deadline imposed by another governing law or a business associate agreement will control.
(f) Retention and Survival. The Provider will retain Health Information only as needed to provide services, satisfy legal record-retention requirements, or address legitimate payment, insurance, or legal matters, and will securely dispose of it when retention is no longer required. The obligations in this Section will survive termination of this Agreement for as long as the Provider retains Health Information. Nothing in this Agreement waives the Client’s privacy rights or limits any obligations imposed on the Provider by HIPAA or other governing privacy laws.
This acknowledgment serves as formal confirmation that the executed Agreement has been received and is incorporated into the official records of Coastal Spirit Wellness LLC.
In the event of an emergency, please contact the following:
Candice Vermillion & Stefan Massie - 321-414-2858 MotivatedMovements@CoastalSpiritWellness.com