Werkshop Release Form
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In consideration of Soul Werk, LLC, allowing Participant to participant in a Soul Werk, LLC sponsored activity, Applicants consent to and/or agree to the following:
Applicants represent, warrant, and verify that Participant is free from illnesses and injuries and that Participant is physically fit and sufficiently trained to participate in all activities associated with the Soul Werk LLC sponsored activity. Participant’s participation in activities and events sponsored by Soul Werk, LLC is voluntary. Applicants consent to administration of first aid and/or other medical treatment to Participant in the event of injury or illness and release and indemnify Soul Werk, LLC and The Cannery from any and all liability or claims arising out of said administration of first aid and/or other medical treatment.
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Participant acknowledges that the Program involves recreational and physical activities that have the risk of harm, and Participant hereby releases and forever discharges Coach and any legal entity owned or controlled by Coach, together with their officers, directors, employees, affiliates, agents, representatives, successors and assigns (collectively the “Indemnitees”) from any and all claims, demands, and causes of action whatsoever which are related to, arise out of, or are in any way connected with the participation by Participant in the recreational and physical activities, including but not limited to claims for damage, loss, injury, cost and expense, which are based upon negligence or misconduct of the Indemnitees or any other person or upon the fitness or safety of the property in which such activities are conducted, or any part thereof, whether naturally occurring or man- made, or any of the fixtures, equipment, materials, or supplies used in the recreational activities, for any purpose. The foregoing release is made not only on behalf of Participant, but also on behalf of Participant’s legal guardian(s), and Client’s estate, heirs, legatees, and all others acting through or on behalf of Participant.
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You (sometimes referred to herein as “Participant”) understand that the information received from me (sometimes referred to herein as “Coach”) in connection with the Program or otherwise should not be seen as medical, nursing or nutrition advice and is certainly not meant to take the place of your seeing licensed health professionals, including your doctor.
You understand and agree that (i) I am not providing health care, medical or nutrition therapy services and will not diagnose, treat or cure in any manner whatsoever, any disease, condition or other physical or mental ailment of the human body, (ii) I am not acting in the capacity of a doctor, licensed dietician-nutritionist, massage therapist, psychologist or other licensed or registered professional, and (iii) you have chosen to work with me and participate in the Program voluntarily.
As your Coach, I encourage you to maintain a relationship with your primary care physician or doctor. In the event that you do not have one and/or do not have routine physicals, I encourage you to do so. Do not discontinue or change any treatment plan that you may be on as a result of our sessions without discussing the change with your doctor.
The undersigned parent or guardian of Participant hereby represents and warrants that he/she is the legal guardian of Participant and that he/she is authorized to bind himself/herself and Participant to the terms and conditions set forth herein. The undersigned parent or guardian agrees to indemnify, defend, and hold harmless Soul Werk, LLC, The Cannery, and/or their respective members, managers, representatives, officers, directors, employees, agents, successors, assigns, medical personnel, and invitees (“Releasees”) from any loss, liability, cost, claim, or damages whatsoever that may be imposed upon Releasees because of any defect or lack of authority to take the actions described herein on behalf of the Participant. The undersigned parent or guardian has read and understands all of the above and voluntarily signs this document. The undersigned parent or guardian further agrees that he/she has not relied upon any representations, statements, or inducements apart from the foregoing written agreement.
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The undersigned hereby grants to Soul Werk, LLC and its successors, assigns, affiliates and licensees the absolute, irrevocable, world-wide, unrestricted, right to use, reproduce, publish, display, digitize, enhance, distort, alter, partition, or otherwise transform, in whole or in part, any and all likenesses of the undersigned, including, without limitation, images, photos, pictures, and video recordings of the undersigned, including same, regardless of format of the undersigned alone or in which the undersigned may be included with others (the “Likenesses”), in any and all media now existing or hereafter created, including without limitation, multimedia. Further, Soul Werk, LLC shall retain all right and title in and to the Likenesses, including without limitation, any copyrights therein, and may, but is not obligated to, use the name of the undersigned in connection with the Likenesses, if Soul Werk, LLC so chooses. In addition, the undersigned hereby transfers and waives or releases any and all Moral Rights and rights of restraint associated with the Likenesses to Soul Werk, LLC on a world-wide and unrestricted basis.
The undersigned hereby releases and discharges Soul Werk, LLC and its licensees from any and all claims and demands arising out of or in connection with the use of the Likenesses, including without limitation any and all claims for libel or invasion of privacy and agrees not to sue or assert any claim against Soul Werk, LLC or any licensee of any nature whatsoever arising by reason of Soul Werk, LLC use of the Likenesses as described hereunder. The undersigned parent or guardian of Participant hereby represents and warrants that he/she is the legal guardian of Participant and that he/she is authorized to bind himself/herself and participant to the terms and conditions set forth herein. The undersigned parent or guardian has read and understands all of the above and voluntarily signs this document. The undersigned has read the foregoing and fully understands the contents thereof. This release shall be binding upon the undersigned, including heirs, legal representatives, and assigns thereof.
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Parent, by his/her signature below, joins in this Agreement and confirms as follows:
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Parent has parental authority with respect to Participant, the Child of Parent, until Participant attains the age of majority.
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Parent approves of this Agreement and the services to be provided by Coach to Participant.
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Parent agrees to assume full responsibility for the payment of all fees and expenses due to Coach pursuant to this Agreement.
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Parent acknowledges that the Program to be provided by Coach to Participant, and any other services provided by Coach to Participant, may involve recreational and physical activities that have the risk of harm, and Parent, on his/her behalf, and on behalf of Participant, hereby releases and forever discharges Coach and any legal entity owned or controlled by Coach, together with their officers, directors, employees, affiliates, agents, representatives, successors and assigns (collectively the “Indemnitees”) from any and all claims, demands, and causes of action whatsoever which are related to, arise out of, or are in any way connected with the participation by Participant in the recreational and physical activities, including but not limited to claims for damage, loss, injury, cost and expense, which are based upon negligence or misconduct of the Indemnitees or any other person or upon the fitness or safety of the property in which such activities are conducted, or any part thereof, whether naturally occurring or man-made, or any of the fixtures, equipment, materials, or supplies used in the recreational activities, for any purpose.
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It is Parent’s intent that this Agreement bind Parent, and all members of my family, including but not limited to my spouse, and my estate, heirs, legatees, and all others acting through or on behalf of Participant (collectively “My Family”). I agree to hold harmless and defend, reimburse and indemnify the Indemnitees from any liability arising out of claims, demands, and causes of action that may be brought by My Family from the participation of Participant in the Program or any other services provided by Coach. I further agree to hold harmless and defend, reimburse and indemnify the Indemnitees from any claims brought by third parties, such as insurance carriers, health care providers, or governmental entities, for reimbursement or other damages as a result of payments to me or the Client.
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Participant certifies as follows with respect to his/her age: (check one)
Thank You For Submitting!
