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.
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.
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.