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RELEASE OF LIABILITY WAIVER AND PHOTO RELEASE

 

 RELEASE OF LIABILITY, WAIVER OF CLAIMS,  ASSUMPTION OF RISK AGREEMENT, AUTHORIZATION FOR EMERGENCY TREATMENT OR TRANSPORTATION, DECLARATION OF FITNESS, AND PHOTO RELEASE.

I, the undersigned, as participant, or as parent or legal guardian of the child listed on this form, hereby assume full responsibility for all risk of injury or loss which may result from my or my child’s participation in the program listed below, and hereby agree to hold harmless, release and forever discharge Nashville Black Wellness Collective, its officers, directors, agents and employees and their representatives, from any and all claims and demands whatsoever which the undersigned, and any of them or any third party and their representatives or any person acting under their behalf have, or may have, against Nashville Black Wellness Collective by reason of any accident, illness, injury, or death to any person or persons, or damage to, loss of or destruction of property arising or resulting directly or indirectly from my or my child’s participation in the aforementioned activity, and occurring during said participation, or anytime subsequent thereto regardless of whether said claims or demands arise out of negligence on the part of Nashville Black Wellness Collective or its leadership. The terms of this release shall serve as a release and assumption of risk for myself, my child, heirs, executives, administrators, and for all of my family members.

I Agree

Declaration of Fitness Agreement: I understand, agree, and acknowledge that some activities in this program may be of a hazardous nature and/or include physical and/or strenuous activity. I hereby assume all risk of such activities. Understanding this, I state to the best of my knowledge that I or my child listed on this form have no medical, physical, mental, or emotional health conditions which would hinder my or my child’s active participation in the program listed on this form.

Furthermore, I hereby declare that I am physically fit and that I have no physical or mental condition(s) that should preclude me from participating in my chosen activity, that I am not participating against medical advice or treatment and that I have not been diagnosed by a registered doctor as having a terminal illness. I further declare that in the event that I feel ill or unwell, have any physical complaints whatsoever or if an injury is sustained of any kind during the course of activities, I will notify the guide immediately and before moving away from the immediate vicinity.

In the case of an emergency in which I am not able to give permission for medical treatment and my designated emergency contact cannot be reached, I authorize the staff or agents of Nashville Black Wellness Collective to obtain whatever medical treatment is deemed necessary for my or my child’s welfare. In the case of my child, this authorization is given pursuant to the provisions of the laws of my state. I further understand and agree that I will be financially responsible for all charges and fees incurred in the rendering of said emergency treatment, regardless of whether my medical insurance would cover such charges and fees.

I Agree

PHOTO RELEASE:​ I hereby grant Nashville Black Wellness Collective permission to use my likeness in a photograph, video, or other digital media (photo) in any and all of its publications, including web-based publications, without payment or other consideration. Should I object to a photo of me being posted or shared by another member, I understand that I need to contact that member directly and ask him/her to remove or take down the image as Nashville Black Wellness Collective is not involved or responsible for that situation.

I Agree


First Participant's Name

First Name*

Last Name*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
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Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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