Alchemy Movement & Healing
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Download Indemnity Form
ALCHEMY MOVEMENT INDEMNITY FORM
SECTION I: PERSONAL INFORMATION
Please note all information is kept private and will never be shared.
(* denotes required fields)
*
Indicates required field
Name
*
First
Last
Date of Birth
*
ID Number
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Email
*
Phone Number
*
Emergency Contact 1
*
Emergency Contact 2
*
Occupation
*
it helps me to know your body if I know what you spend your day doing
How did you hear about Alchemy Movement?:
*
*
SECTION II: RISK ASSESSMENT
Heart Disease
*
Yes
No
Shortness of Breath or Chest Pain
*
Yes
No
Inhaler?
*
Yes
No
if
“Y
es”, please bring it to every class
High Blood Pressure
*
Yes
No
Blood pressure levels, if known
*
High Cholesterol Level
*
Yes
No
Significant Bone/Joint/Muscle Pain
*
Yes
No
Location of Pain
*
Back Pain
*
Yes
No
Location of Pain
*
Cigarette Smoking
*
Yes
No
Diabetes
*
Yes
No
Insulin Dependent
*
Yes
No
Are you pregnant?
*
Yes
No
If "Yes", how many weeks?
*
Have you had any surgical procedures in the last 5 years?
*
Yes
No
Procedure?
*
Any others? Please explain
*
Are you physically active?
*
Yes
No
What type of activity or exercise?
*
Are you currently taking any medication?
*
Yes
No
Type of Medication
*
What do you hope to achieve in your Healing/Meditation/Pliates/Yoga Sessions?
*
*
SECTION III: AGREEMENT
1. In consideration of participating in classes at Alchemy Movement, I agree and acknowledge that I am fully aware that participation in the classes involves risks and I accept all the risks of participating, even if the risks are created by the carelessness, negligence or gross negligence of a Released Party (as defined below) or anyone else.
2. “
Claims
” includes but is not limited to any and all liabilities, claims, demands, legal actions, rights of actions for damages, personal injury or death in connection with participation in the classes. “
Released Party
” means
Alchemy Movement
or any of its affiliates, employees or volunteer staff.
3. I agree and acknowledge that:
a. I am in proper physical condition to participate in the classes, and am aware that participation could, in some circumstances, result in physical injury, serious physical injury or death.
b. I understand my physical limitations and am sufficiently self-aware to stop physical activity before I become ill or injured.
4. I agree not to sue any Released Party for Claims, even if the Claims arise from the carelessness, negligence or gross negligence of any Released Party or anyone else. I agree to indemnify (reimburse for any loss) and hold harmless each Released Party from any loss or liability (including any reasonable legal fees they may incur) defending any Claim made by me or anyone making a Claim on my behalf, even if the Claim is alleged to or did result from the carelessness or negligence of any Released Party or anyone else.
5. No warranties or representations have been made to me about the classes which are not stated on this form. I understand and intend that this document act as the broadest and most inclusive assumption of risk, waiver, release of liability, agreement not to sue and indemnity.
6. If any provision of this agreement shall be unlawful, void or for any reason unenforceable, then that provision shall be deemed severable from this agreement and shall not affect the validity and enforceability of any remaining provisions.
7. I have fully read and understand this agreement. I am aware that by signing this agreement, I am waiving certain legal rights I or my heirs, next of kin, executors, administrators and assigns may have against the Released Party.
*
I also understand that:
(please type "YES, INITIALS" in each box provided)
Classes are booked for the month in advance and all payments are non-refundable, including, but not limited to vacation, illness or injury. Provision will be made for classes canceled with a 24 hour notice and all classes cancelled by Alchemy Movement will be credited in full.
Agreed
*
I take responsibility for taking my temperature before attending my private sessions as well as adhering to all the safety precautions set out by the South African government. I also take responsibility for my own health and safety and understand that although Alchemy Movement takes every precaution to safe guard clients well-being if I should become ill I have no legal claim or recourse against Gisela Bean or any other Alchemy Movement employees.
Agreed
*
I will notify instructors immediately of any pain and/or major discomfort felt during any class.
Agreed
*
If I am pregnant or plan to become pregnant during the course of attending classes, I will inform my instructor.
Agreed
*
BY FILLING IN NAME BELOW AND SUBMITTING FORM, Participant accepts and agrees to the terms and provisions contained in this agreement.
Name in Full
*
Date
*
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