Terms and Conditions
This liability waiver, (“Agreement”), executed this _____ day of _________________, 2023, is entered into by and between SpoonMoon LLC, an Arkansas limited liability company, and its related entities and affiliates, (“SpoonMoon”) and ______________________________, an individual and resident of Arkansas (“Participant”).
PARTICIPANT INFORMATION
Name (First and Last): ______________________ Phone Number:___________________________ Mailing Address: __________________________ Email Address: ___________________________
__________________________
Participation in Fitness/Wellness programs, classes, and related services is voluntary and, if necessary, should be undertaken on the basis of personal medical advice. Completion of the PAR-Q (Physical Activity Readiness Questionnaire) is mandatory for participation.
1. Hasadoctorormedicalprofessionaleversaidthatyouhaveaheartconditionandthatyou should only do physical activity as recommended by a doctor?
Yes- No-
2. Do you feel pain in your chest when you do physical activity?
Yes- No-
3. In the past month, have you had chest pain when you were not doing physical activity?
Yes- No-
4. Do you lose your balance because of dizziness or do you ever lose consciousness?
Yes- No-
5. Doyouhaveaboneorjointproblemthatcouldbemadeworsebyachangeinyourphysical
activity?
Yes- No-
6. Is your doctor currently prescribing drugs for your blood pressure or heart condition?
Yes- No-
7. Are you currently injured in any manner that would limit your physical activity?
Yes- No-
8. Do you know of any other reason why you should not do physical activity?
Yes- No-
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LIABILITY WAIVER
If you answered YES to one or more questions: Talk with your doctor by phone or in person BEFORE you start becoming more physically active or BEFORE you participate in a fitness/wellness activity. Tell your doctor about this questionnaire and which questions you answered YES.
• You may be able to do any activity you want—as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those which are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice.
• Find out which fitness/wellness activities are safe and helpful for you.
If you answered NO to all questions: If you answered NO honestly to all eight questions, you can:
• Become more physically active—begin slowly and build up gradually.
• Take part in fitness/wellness activities.
DELAY BECOMING MORE ACTIVE IF:
• You are not feeling well because of a temporary illness or injury—wait until you feel better;
or
• You are or may be pregnant—talk to your doctor before you start becoming more active.
SpoonMoon, LLC assumes no liability for individuals who undertake physical activity or participate in physical or wellness programs, classes, or services, and if in doubt after completing this questionnaire, consult your doctor prior to physical activity.
I have read, understood, and completed this questionnaire truthfully. Any questions I had were answered to my full satisfaction.
I fully understand that my participation in any fitness/wellness activities, programs, classes, and related services is at my own risk. I will not hold liable SpoonMoon LLC, the activity instructor, any service providers, and/or any staff member or responsible for the personal injury, accident, and/or accidental death resulting from my participation in activities, programs, classes, or related services.
In consideration of being permitted to participate in fitness/wellness activities, programs, classes, and related services conducted by SpoonMoon LLC and its affiliates, which may consist of warm-up, flexibility activities, cardio respiratory activities, muscular strength and endurance activities, lifting weights, stationary cycling, and/or fitness assessments, I have volunteered to participate in a program of progressive physical exercise. I waive any possibility of personal damage which may be blamed upon such a program in the future and accept the responsibility for accepting such exercise and assistance. _______(initials)
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LIABILITY WAIVER
PLEASE NOTE: IF YOUR HEALTH CHANGES SO THAT YOU THEN ANSWER YES TO ANY OF THE AFOREMENTIONED QUESTIONS, CONTACT YOUR PHYSICIAN IMMEDIATELY, BEFORE CONTINUING THE FITNESS/WELLNESS ACTIVITY.
I understand there exists the possibility of certain physiological changes during the program. These include elevated heart rate, muscle or joint pain, abnormal blood pressure, fainting, irregular, fast, or slow heart rhythm, and in rare instances, heart attack, stroke, or death. I acknowledge and accept these risks. Information that I provide about my health status or previous experiences of heart-related symptoms with physical effort may affect my safety. I accept responsibility for fully disclosing my relevant medical history, as well as symptoms that may occur during my activities with SpoonMoon LLC and its affiliates. To my knowledge, I do not have any limiting physical condition or disability which would preclude any activities with SpoonMoon LLC or its affiliates. I understand that I am responsible for monitoring my own condition throughout exercising, and should any unusual symptoms occur, I will cease my participation and inform the instructor of the symptoms. Unusual symptoms include, but are not limited to: chest discomfort, nausea, difficulty in breathing, and/or joint or muscle pain or strains. _________(initials)
Other risks of participation in fitness/wellness activities, programs, classes, and related services include, but are not limited to: trips, falls, collisions, sprains, strains, cuts, bruises, lacerations, or broken bones. I understand that the risks and dangers of participation are real. I am still interested in participating and will hold harmless SpoonMoon LLC, SpoonMoon LLC, the activity instructor, any service providers, and/or any staff member or affiliates involved in this program. I agree that I, my heirs, or any family member will not hold SpoonMoon LLC, SpoonMoon LLC, the activity instructor, any service providers, and/or any staff member or affiliates responsible for any injuries that may occur during any part of the program. For the right to participate in this program, I freely sign away my rights to sue for such injuries or damages. _________(initials)
An examination by a physician should be obtained by all participants prior to involvement in an exercise program. If a participant refuses to obtain a physician’s consent, he/she must sign the following statement:
I, ______________________, have been informed of the need for a physician’s approval for participation in a progressive exercise and fitness program. I fully understand the strenuous nature of the program and accept complete responsibility for my health and well-being in the voluntary exercise and fitness program and related testing. _______(initials)
I HAVE READ THE RELEASE OF LIABILITY AND ASSUMPTIONS OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS AND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
Participant’s Signature____________________________ Date___________________________
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