INCLŪSIV WELLNESS CENTER
RELEASE OF LIABILITY, WAIVER & ASSUMPTION OF RISK AGREEMENT
4142 Main Street, Kansas City, MO 64111
Participant Name: {first_name} {name}
Date of Birth: {dob}
Address: {address}
Phone Number: {phone}
Email:
Emergency Contact: {contact_name}
Emergency Contact Phone: {contact_phone}
Relationship to Participant: {contact_relation}
ASSUMPTION OF RISK
I acknowledge that participating in fitness training, physical activity, mental wellness programming, and other services offered by INCLŪSIV Wellness Center (“INCLŪSIV”) involves risks. These risks may include, but are not limited to, bodily injury, aggravation of preexisting conditions, and in rare cases, serious medical events. I affirm that I am voluntarily participating and assume full responsibility for any risks or injuries incurred.
Initials:
MEDICAL ACKNOWLEDGMENT
I affirm that I am in good health and physically able to participate in INCLŪSIV’s programs. I acknowledge that it is my responsibility to consult a physician before participating if I have any health concerns. I will disclose any relevant medical conditions that may affect my ability to participate.
Initials:
WAIVER & RELEASE OF LIABILITY
In consideration of the services and programs provided by INCLŪSIV, I waive, release, and discharge INCLŪSIV Wellness Center, its staff, volunteers, affiliates, and partners from any and all claims for injury, illness, death, or property damage that may arise during or after my participation.
Initials:
INDEMNIFICATION
I agree to indemnify and hold harmless INCLŪSIV and its team from any loss, liability, or cost, including attorney’s fees, that may result from my participation or behavior at the facility.
Initials:
MEDIA RELEASE
I grant INCLŪSIV permission to take photos or videos of me for promotional, marketing, or educational purposes.
I agree to the media release.
I do not agree to the media release.
Initials:
MINOR PARTICIPANT WAIVER (if applicable)
If I am signing on behalf of a minor, I confirm that I am the legal parent/guardian and give full consent for the minor to participate in INCLŪSIV’s programs. I agree to all terms outlined above on their behalf, including emergency medical treatment if necessary.
Initials:
I certify that I have read this agreement and fully understand its contents. I voluntarily agree to the terms and conditions stated above.
Signature of Participant or Legal Guardian:
Date Signed: {sign_date}
OPTIONAL FIELDS:
Upload supporting documentation: /
Notes or accommodations needed:
Member portal: {login_link}
This waiver applies to all services, classes, and programs provided at INCLŪSIV Wellness Center’s physical location at 4142 Main Street, Kansas City, MO 64111.
