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HEALTH & WELLNESS PROGRAM

EXPRESS ASSUMPTION OF RISK, RELEASE OF LIABILITY, WAIVER OF CLAIMS,

INDEMNITY AGREEMENT

Please read and be certain you understand the implications of signing.

 

Express Assumption of Risk Associated with 10th Planet & The Happier Life Project Health & Wellness Program and Related Activities:

I understand and agree that there exist risks of harm associated with participating in The Happier Life Projects Health & Wellness Program at 10th Planet which may give rise to bodily injury, property damage and/or death. These risks include, but are not limited to, equipment failure, inadequate safety equipment, those hazards associated with strenuous activity, the unavailability of adequate medical care, exposure and emergencies related to heat or cold weather, personal injury including serious physical and/or mental trauma or death, exhaustion, dehydration, broken bones, concussion, torn appendages, dislocations, bruises, cuts, infections, and any other injuries that may result in physical contact with others. I further understand and agree that there may be risks and dangers not known or reasonably foreseeable at this time.

 

I understand that The Happier Life Projects Health & Wellness Program may consist of transportation to and from activities and mild to strenuous exercise. I understand and agree that included within the scope of this waiver and release is any cause of action, arising from the performance of or the failure to perform maintenance, inspection, supervision or control of the Program, or the failure to warn of existing dangerous conditions not known to or reasonably discovered by THLP, including all acts of negligence of THLP the negligence of others, or by the negligence of THLP, its officials, officers, employees, agents, volunteers or co-sponsors of the THLP Health & Wellness Program, may cause these risks and dangers. I knowingly and voluntarily assume full responsibility for these risks arising out of or related to my participation in THLP H&W Program.

Release of Liability, Waiver of Claims and Indemnity Agreement:

In consideration for being permitted to participate in any way in the THLP H&W Program and related activities, I hereby agree, acknowledge and appreciate that:

1. I HEREBY RELEASE AND HOLD HARMLESS WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER CAUSED BY NEGLIGENCE OR OTHERWISE, the following named persons or entities, 10th Planet and/or THLP herein referred to as releasees.

2. To release the releasees, their officers, directors, staff, employees, representatives, agents, co-sponsors and volunteers, from liability and responsibility whatsoever and for any claims or causes of action that I, my estate, heirs, survivors, executors, or assigns may have for personal injury, property damage, or wrongful death arising from the above activities whether caused by active or passive negligence of the releasees or otherwise. By executing this document, I agree to hold the releasees harmless and indemnify them in conjunction with any injury, disability, death, or loss or damage to person or property that may occur as a result of engaging in the above activities.

3. By entering into this Agreement, I am not relying on any oral or written representation or statements made by the releasees, other than what is set forth in this Agreement. This release shall be binding to the fullest extent permitted by law. If any provision of this release is found to be unenforceable, the remaining terms shall be enforceable.

 

I HAVE CAREFULLY READ, AND I UNDERSTAND, ACKNOWLEDGE AND AGREE TO THIS RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT. I UNDERSTAND THAT I AM GIVING UP VALUABLE LEGAL RIGHTS BY SIGNING THIS AGREEMENT, AND I SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. I UNDERSTAND THAT THIS AGREEMENT REPRESENTS A CONTRACT BETWEEN LOS ANGELES RECOVERY CONNECT (LA RECOVERY CONNECT) AND MYSELF. I HAVE VOLUNTARILY CHOSEN THE ACTIVITIES IN WHICH I AM PARTICIPATING.

Address:___________________________________________________________________

Phone #:___________________________________________________________________

Emergency Contact Name:____________________________________________________

Emergency Contact Phone #: __________________________________________________

Please Check One of the Following:

□ I have medical and accident insurance with: _______________________________

Policy # ______________________________________________________________

□ I have no medical or accident insurance, and I agree to pay any medical and/or dental expenses directly or indirectly related to my participation.

ACCEPTED AND AGREED ON (DATE): ________________________________

ADULT PARTICIPANT:

_______________________________

PARTICIPANT'S SIGNATURE

_______________________________

NAME (PLEASE PRINT)

 

IF INDIVIDUAL IS A MINOR OR INCAPACITATED IN ANY RESPECT:

__________________________________

PARENT/LEGAL GUARDIAN’S SIGNATURE

__________________________________

NAME (PLEASE PRINT)

 

MEDIA CONSENT AND RELEASE

I, the undersigned person, for good and valuable consideration, have granted permission to THLP to use my name, image, voice, performance and likeness (collectively, “Likeness”) as such Likeness appears in photography and video shot in connection with THLP (the “Organization”), and/or any other production, and in connection with advertising, publicizing, exhibiting and advocating for Recovery and/or the Organization, in whole or in part, by any and all means, media, devices, processes and technology now or hereafter known or devised in perpetuity throughout the universe.

● I hereby irrevocably grant and assign my services to be owned by THLP, all rights, title and interest in my appearance and performance.

● I understand that THLP has no obligation to utilize my Likeness. 

● THLP’s exercise of such rights shall not violate or infringe any rights of any third party. I understand that LA Recovery Connect has been induced to proceed with the production, distribution and use of my Likeness in reliance upon this agreement.

● I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the image.

All of the above rights are granted without any restriction or reservation of any kind or nature whatsoever and without any right on any part to enjoin or interfere with the production, distribution or any use of my Likeness. By signing this, I hereby release THLP from any and all claims and demands arising out of or in connection with such use, including, without limitation, any and all claims for invasion of privacy, infringement of my right of publicity, defamation (including libel and slander), false light and any other personal and/or property rights.

I represent that I am of sound mind and body and have entered into this agreement knowingly and willingly. I am of full legal age and have the right to sign this contract in my own name. If I am not of full legal age, a parent or guardian will sign on my behalf.

ACCEPTED AND AGREED:

________________________________________

SIGNATURE

________________________________________

NAME (PLEASE PRINT)

___________________________________________

TITLE (AS YOU WOULD LIKE IT TO APPEAR)

________________________________________

ADDRESS

________________________________________

CITY/STATE/ZIP

________________________________________

TELEPHONE NUMBER

IF INDIVIDUAL IS A MINOR OR INCAPACITATED IN

ANY RESPECT:

__________________________________________

PARENT/LEGAL GUARDIAN’S SIGNATURE

__________________________________________

NAME (PLEASE PRINT)

__________________________________________

TELEPHONE NUMBER

 

 




First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Additional Information

Emergency Contact First and Last Name *

Emergency Contact phone Number *
Please check one of the following: *
I have medical and accident insurance
I have no medical or accident insurance, and I agree to pay any medical and/or dental expenses directly or indirectly related to my participation.
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Additional Information

Emergency Contact First and Last Name *

Emergency Contact phone Number *
Please check one of the following: *
I have medical and accident insurance
I have no medical or accident insurance, and I agree to pay any medical and/or dental expenses directly or indirectly related to my participation.
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Additional Information

Emergency Contact First and Last Name *

Emergency Contact phone Number *
Please check one of the following: *
I have medical and accident insurance
I have no medical or accident insurance, and I agree to pay any medical and/or dental expenses directly or indirectly related to my participation.
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Additional Information

Emergency Contact First and Last Name *

Emergency Contact phone Number *
Please check one of the following: *
I have medical and accident insurance
I have no medical or accident insurance, and I agree to pay any medical and/or dental expenses directly or indirectly related to my participation.
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Additional Information

Emergency Contact First and Last Name *

Emergency Contact phone Number *
Please check one of the following: *
I have medical and accident insurance
I have no medical or accident insurance, and I agree to pay any medical and/or dental expenses directly or indirectly related to my participation.
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Additional Information

Emergency Contact First and Last Name *

Emergency Contact phone Number *
Please check one of the following: *
I have medical and accident insurance
I have no medical or accident insurance, and I agree to pay any medical and/or dental expenses directly or indirectly related to my participation.
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Additional Information

Emergency Contact First and Last Name *

Emergency Contact phone Number *
Please check one of the following: *
I have medical and accident insurance
I have no medical or accident insurance, and I agree to pay any medical and/or dental expenses directly or indirectly related to my participation.
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Additional Information

Emergency Contact First and Last Name *

Emergency Contact phone Number *
Please check one of the following: *
I have medical and accident insurance
I have no medical or accident insurance, and I agree to pay any medical and/or dental expenses directly or indirectly related to my participation.
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Additional Information

Emergency Contact First and Last Name *

Emergency Contact phone Number *
Please check one of the following: *
I have medical and accident insurance
I have no medical or accident insurance, and I agree to pay any medical and/or dental expenses directly or indirectly related to my participation.
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Additional Information

Emergency Contact First and Last Name *

Emergency Contact phone Number *
Please check one of the following: *
I have medical and accident insurance
I have no medical or accident insurance, and I agree to pay any medical and/or dental expenses directly or indirectly related to my participation.
Parent or Guardian's Email Address

Email*

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

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Additional Information

Emergency Contact First and Last Name *

Emergency Contact phone Number *
Please check one of the following: *
I have medical and accident insurance
I have no medical or accident insurance, and I agree to pay any medical and/or dental expenses directly or indirectly related to my participation.
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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