Questionnaire – Elements Recovery Zone

Liability Waiver for Use of Elements Recovery Zone
Acknowledgement and Release of Liability I request authorization for to use Elements Recovery Zone (Hereafter the Facility.) I acknowledge that use of the Facility is expressly conditioned on my agreement to each of the terms and conditions of this Agreement. I acknowledge and agree as follows: I understand that the staff does not diagnose illness or prescribe medical treatments or pharmaceuticals and that services rendered by the staff are not medical in nature and are not a substitute for diagnosis and treatment by a licensed medical professional. Furthermore, if I have a medical diagnosis, I have consulted a physician and have been released to participate in the Facility. Use of the Facility involves physical activities that may cause injury. I understand that there is an inherent risk of injury when choosing to participate In any physical activity. My use of the Facility is a voluntary choice in all respects, and I assume all risks of injury and illness that result from such use. As the participant, I recognize and acknowledge that there are risks of physical injury and I agree to assume the full risk of any injuries (including death), damages, or loss which I may sustain from participating in any and all activities arising out of, connected with or in any way associated with my use of the Facility. I acknowledge that participation and use of the Facility is voluntary. I do hereby fully release and discharge the Facility, their agents, their successor and assigns, employees and all associated persons, and those whose facilities are being used for this activity (collectively, the “Released Parties”) from any and all liability, claims, and causes of action from injuries or illness (including death), damages or loss which I may have or which may occur to me from participating in all activities utilizing the Facility. This is a complete and irrevocable release and waiver of liability. Specifically, and without limitation, I hereby release the Facility from any liability, claim, or cause of action arising out of the Facility’s negligence. I agree not to sue the Facility for any alleged liabilities, claims, or causes of action released hereunder. I further agree to indemnify and hold harmless and defend the Facility from all claims resulting from injuries, or illness (including death), damages, or loss, including, but not limited to attorneys’ fees, sustained by me arising out of, connected with, or in any ways associated with, the Facility. The Facility prohibits tobacco, drugs, alcohol, or firearms. In the event of any emergency, I authorize the Facility to secure from any licensed hospital, physician, and/or medical personnel any treatment deemed necessary from my immediate care and agree that I will be responsible for payment of all medical services rendered. I have been advised by the Facility to consult with a physician before I undertake any usage of equipment. I certify that I am in good health and sufficient physical condition to properly use the Facility. I understand and agree to adhere to the Facility’s policies and procedures, which are available in each Facility room. Users are responsible for leaving the Room clean and following the posted rules and procedures for safe use. Problems with any equipment should be reported to the Facility personnel. No Facility property is to be removed from the premises. Failure to observe the rules and procedures can result in termination of access to the premises. I have read and fully understand this Acknowledgement and release of Liability as stated above, including the permission to secure medical treatment and the release of all claims, including claims of the negligence of the Facility. I understand that my waiver will be retained by the Facility. This document is binding upon me and my heirs, children, wards, personal representatives and anyone else entitled to act on my behalf.

I agree

Intake Questionnaire and Waiver

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