Loading...

Life Center Fitness

Informed Consent Agreement

Thank you for choosing to use the facilities, services or programs of Fountain of Life Center. We request your understanding and cooperation in maintaining both your and our safety and health by reading and signing the following informed consent agreement.

I declare that I intend to use some or all of the activities, facilities, programs, and services offered by Fountain of Life Center and I understand that each person, (myself included), has a different capacity for participating in such activities, facilities, programs, and services. I am aware that all activities, services, and programs are either educational, recreational or selfdirected in nature. I assume full responsibility, during and after my choices to use or apply, at my own risk, any portion of the information or instruction I receive. I understand that part of the risk involved in undertaking any activity or program is relative to my state of fitness of health (physical, mental, or emotional) and to the awareness, care and skill with which I conduct myself in that activity or program. I acknowledge that my choice to participate in any activity, service, and program of Fountain of Life Center brings with it, my assumption of those risks or results stemming from this choice and the fitness, health, awareness, care, and skill that I possess and use. I further understand that the activities, programs, and services offered by Fountain of Life Center are sometimes conducted by personnel who may not be licensed, certified, or registered instructors or professionals. I accept the fact that the skill and competencies of some employees and/or volunteers will vary according to their training and experience and that no claim is made to offer assessment or treatment of any mental or physical disease or condition by those who are not duly licensed, certified or registered and herein employed to provide such professional services.

I recognize that by participating in the activities, facilities, programs, and services offered by Fountain of Life Center, I may experience potential health risks including but not limited to transient light-headedness, abnormal blood pressure, chest discomfort, leg cramps, and nausea and that I assume willfully those risks. I acknowledge my/our obligation to immediately inform the nearest supervising employee of any pain, discomfort, fatigue or any other symptoms that I may suffer during and immediately after my participation. I understand that I may stop or delay my/our participation in any activity or procedure if I so desire and that I may also be requested to stop and rest by a supervising employee who observes any symptoms of distress or abnormal responses. I further understand that such supervising employees are in no way obligated to make such a request and will not be liable for failing to supervise or in any way monitor my activities, facilities, programs, and services offered by Fountain of Life Center at any time before or after my participation. I further understand that any answer or explanation offered is not meant to be construed as medical advice and I agree that I are responsible for verifying such advice with my doctor or other medical professionals.

Agreement & Release of Liability

1. In consideration of gaining membership or being allowed to participate in the activities and programs of Fountain of Life Center and use its facilities, equipment in addition to the payment of any fees or charge, I DO HEREBY WAIVE, RELEASE ANDFOREVER DISCHARGE Fountain ofLifeCenter and its officers, agents, employees, representatives,successors or assigns andallothersfromany and allresponsibilities orliability for injuries or damages resulting from my activities or my use of equipment ormachinery arising out ofmy participation in any activities at Fountain ofLifeCenter. I/We do hereby also release all of those mentioned and any others acting upon their behalf from any responsibility or liability for any injury or damage to myself/ourselves, including those caused by the negligent act or omission ofthose mentioned or others acting on their behalfin any way arising out of or connected with participation in any ofthose mentioned or others actingFountain ofLifeCenter.

I Agree

2. I understand and am aware that strength, feasibility, and aerobic exercise, including the use of equipment, is a potentially hazardous activity. I also understand the fitness activities involve a risk of injury and even death and that I am/we are voluntarily participating in these activities and using equipment with knowledge of the dangers involved. I hereby agree to expressly assume and accept any and all risks of injury or death.

I Agree

3. I do hereby further declare myself to be physically sound and suffering from no condition, impairment, disease, infirmity or other illness that would prevent my participation in any of the activities and programs of Fountain of Life Center or use of equipment except as hereinafter stated. I have decided to participate in activity and/or use of equipment with or without the approval of my physician and do hereby assume all responsibility for my/our participation and utilization of equipment in my/our activities.

I Agree

I declare that I/we have read, understood and agreed to the contents of this informed consent agreement in its entirety.

Coronavirus Liability Release and Waiver

The BURLINGTON ASSEMBLY OF GOD-FOUNTAIN OF LIFE CENTER, is a New Jersey nonprofit corporation (the “Owner”), that owns and operates the Life Center (the “Life Center”), principally located at 2035 Columbus Road, Burlington, NJ 08016. In consideration for allowing me (and my dependents) to enter the Life Center to participate in activities hosted by the Sponsoring Organization (the “Organization”) or Event Host at the Life Center, I, on behalf of myself and my dependents, acknowledge and agree to the terms of this Coronavirus Liability Release and Waiver (the “Waiver”), as evidenced by my signature below:

1. I am entering the Owner’s premises as a guest of the Organization or Event Host, and the Owner is allowing the Organization or Event Host and its guests to use the Life Center only if a signed waiver, in this form, is obtained from each guest.

2. The World Health Organization (“WHO”) has declared the novel Coronavirus (COVID-19) a worldwide pandemic. While the state of medical knowledge is evolving, it is known that the virus has the capacity to transmit from person-to-person through respiratory droplets and/or by contact with contaminated surfaces and objects. People reportedly can be infected and show no symptoms and therefore spread the disease. The exact methods of spread and contraction are unknown, and there is no known cure for COVID-19. Evidence has shown that COVID-19 can cause serious and potentially life threatening illness and even death.

3. The Centers for Disease Control and Prevention (“CDC”), the New Jersey Department of Health, and many local jurisdictions have set forth guidelines to prevent the spread of the virus, which the Life Center and persons entering the Life Center must comply with, including but not limited to, social distancing measures, increased hand-washing and other hygienic practices, and frequent cleaning of common surfaces.

4. However, it is not possible to prevent the presence of COVID-19 at any premises. Accordingly, I am aware that the Owner cannot prevent me or my dependents from becoming exposed to, contracting, or spreading COVID-19 while at the Life Center or utilizing any of its facilities or services. Therefore, if I (or my dependents) freely choose to enter the Life Center’s premises, rather than arranging for an alternative method of enjoying the same services, activities, or events virtually (e.g. virtual conferences or events), and utilize the Life Center’s facilities in person, I (or my dependents) may be exposed to and/or have an increased risk of contracting or spreading COVID-19.

5. I, on behalf of myself and my dependents, understand and hereby assume any and all COVID-19 risks associated with entering and utilizing the Life Center’s premises, including, but not limited to, any risks that may arise from contracting COVID-19 due to the negligence of the Owner and each of its affiliates, including, but not limited to, any of its owners, officers, directors, managers, officials, trustees, agents, employees, volunteers, representatives, successors or assigns (the “Released Parties”), and hereby knowingly release the Owner from any and all liability from any medical condition or illness (including without limitation COVID-19) contracted while using the Life Center’s facilities. This Coronavirus Liability Release and Waiver (the “Waiver”) fully and forever releases Owner or any Released Party from any and all responsibility of any nature to me and/or my dependents arising from or in any way related to exposure to the COVID-19 virus while participating in activities at the Life Center, even if the exposure results from the negligence of a Released Party. I hereby forever release and waive my right to bring suit, whether on behalf of me or any of my dependents, against Owner or any Released Party, in connection with exposure, infection, and/or spread of COVID-19 related to participating in any event or activity at the Life Center, including without limitation any claims for personal injuries, physical injuries, bodily harm, death, disease or property losses, or any other loss, including but not limited to claims of negligence, and I, on behalf of myself and my dependents, give up any rights to seek damages from the Owner or any Released Party with respect to any such claim, whether known or unknown, foreseen or unforeseen.

6. Neither I nor any dependent will enter the Life Center premises for any reason if such person (or any member of their household) has:

a. experienced symptoms of fever, fatigue, difficulty in breathing, or dry cough or exhibited any other symptoms relating to COVID-19 during the 14 day period prior thereto;

b. traveled to or returned to New Jersey from any of the states listed on the New Jersey travel advisory list during the 14 day period prior thereto;

c. traveled internationally by sea or by air during the 30 day period prior thereto;

d. has been diagnosed or infected with COVID-19 and not medically cleared for participation in activities outside their home.

7. I understand and agree that the laws of the State of New Jersey will apply to this Waiver and this Waiver of liability shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.

I HAVE CAREFULLY READ AND FULLY UNDERSTAND ALL PROVISIONS OF THIS WAIVER, AND FREELY AND KNOWINGLY ASSUME THE RISKS AND WAIVE ANY AND ALL RIGHTS CONCERNING LIABILITY AS DESCRIBED ABOVE. 

I Agree

I am the parent or legal guardian of the minor(s) named above. I have the legal right to consent to and, by signing below, I hereby do consent to the terms and conditions of this Waiver.

Today's date: July 25, 2021

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
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.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!