Seniors Fitness Program
Street Address Line 2
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Emergency Contact Information
Physical Activity Waiver & Release:
I am voluntarily participating in the exercise classes of the Grow-Well Seniors Fitness Program provided by Seniors Forum ICCM at my own risk. I recognize that this program requires physical exertion that may
be strenuous at times and may cause physical injury. I am fully aware of the risks and hazards involved.
I agree that I am voluntarily participating in these activities and the use of the equipment, facilities, and premises and assume all risks of injury, illness, or death. Such injuries may include but are not limited to, heart
attacks, muscle pulls, muscle strains, muscle tears, broken bones, shin splints, injuries to the shoulder, injuries to the back, injuries to knees, injuries to the foot, or any other illness or soreness, including death.
I am aware that it is my responsibility to consult with a physician prior to and regarding my participation in the exercise classes of the Grow-Well Seniors Fitness Program provided by ICNA Milton (ICCM), a project of ICNA Canada. I am aware ICNA Milton (ICCM) and ICNA Canada are not responsible for any loss of my personal property.
I understand that I will be taking part in regular fitness assessments in order to track my personal progress, and I am aware that the information obtained from these assessments will remain confidential between me and the fitness instructor. I acknowledge that the results from my assessment may be used for data collection purposes, however, I will remain completely anonymous. I am knowledgable of the fact that if I do not feel comfortable complying with the aforementioned portion of the program, I am free to opt-out of participating in fitness assessments at any time and able to request that my data be removed from all records.
I, the undersigned participant, understand and agree that the class nor its owners, operators, agents, or instructors may be held liable in any way for any occurrence in connection with my physical fitness and performance, which may result in injury, death, or damage to me or my family, heirs, or assignees.
I, the undersigned hereby release ICNA Milton (ICCM), ICNA Canada, their consultants, employees, and volunteers from any and all liability, claims, demands, actions or rights of action, which are related to, arise out of, or are in any way connected with my participation in this activity, including those allegedly attributed to the negligent acts or omissions of the above mentioned parties. This agreement shall be binding upon me, my successors, representatives, heirs, executors, assigns, or transferees. If any portion of this agreement is held invalid, I agree that the remainder of the agreement shall remain in full legal force and effect.
I also give full permission for any person connected with ICCM Seniors Forum to administer first aid deemed necessary, and in case of serious illness or injury, I give permission to call for medical and or surgical care and to transportation to a medical facility deemed necessary.
I have read and understood the foregoing assumption of risk,and release of liability and I understand that by submitting the registeration form obligates me to indemnify the parties named for any liability for injury or death of any personand damage to property caused by my negligent or intentional act or omission. Iunderstand that by signing this form I am waiving valuable legal rights.
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