1. Why am I being asked to sign this form?
As a Retreat Participant, I have submitted a Physician’s Release signed by my physician. In addition, I, and an adult accompanying me if applicable, will be screened by a PWR! professional to determine eligibility and ability to participate, including functional mobility, cardio-respiratory, and muscular fitness, and personal fitness and mobility goals. This information will be used to make recommendations concerning safe and appropriate level and degree of participation in physical exercise during the Retreat.
BY SIGNING BELOW, I UNDERSTAND AND AGREE THAT:
a) The screening is not a comprehensive or complete medical evaluation;
b) The Retreat program is not medically supervised;
c) My decision to participate is based solely on my own judgment and the release of my physician, and
d) I may bring another adult with me (“Care Partner”), who shall agree to and sign below (“My Release”) as a condition of participating.
2. I Understand the Risks
I ACKNOWLEDGE AND UNDERSTAND that there are risks for persons with Parkinson Disease who participate in physical exercise and exertion, including the risk of injury to the musculoskeletal system, and in rare cases even heart attack or death. I further understand that even with diligent efforts by NeuroFit Networks, Inc. to minimize risks, such risks remain.
3. My Release
If I am injured while participating in PWR! Retreat programs, I do hereby release, acquit, hold harmless and forever discharge NeuroFit Networks, Inc., dba Parkinson Wellness Recovery | PWR!, and The Scottsdale Resort at McCormick Ranch, their Boards, Officers, employees, agents, servants, volunteers, and all persons, natural or corporate, in privity with them or any of them (“Indemnified Persons”), from any and all claims or causes of action of any kind whatsoever, including but not limited to actions, suits and/or claims for any bodily injuries, death or property damage which may be sustained by me while participating in any activities during and on the PWR! Retreat, (including travel to and from the Retreat), resulting from the negligence or lack of care due or claimed to be due to the conduct of Indemnified Persons.
I hereby give and grant to any licensed medical doctor or hospital my consent and authorization to render such aid, treatment, or care to me as in the judgment of such doctor or hospital may be required on an emergency basis, in the event I should be injured or stricken ill while participating in the PWR! Retreat. I further agree that any expense incurred for such medical care will be paid by my insurance or me. I also understand that if I need to be sent home for any reason (i.e., illness, injury), I will be responsible for any and all expenses incurred.
MY SIGNATURE BELOW CONFIRMS THAT I HAVE READ THIS WAIVER AND RELEASE IN ITS ENTIRETY AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY.
As a Participant, I confirm that I have fully disclosed to my physician for the Physician’s Release and to PWR! during the intake screening process all material information related to my medical condition and medical history. Unless terminated in writing, this release shall be effective for one year from the date signed below.