Updated Dec. 2, 2020
This electronic form serves as the informed consent and liability waiver document for the Active Moms: Postpartum Foundations Virtual Group Fitness Workshop provided by Alex Courts with Vibrant Physical Therapy & Wellness, LLC.
Disclosure of Information
1. I hereby authorize Alexandra Randolph Courts to perform the following fitness, wellness, and preventative services, exercises, client education and other similar techniques on me in the group setting: screening, general exercise instruction, general movement instruction (including body mechanics), general postural and positioning instruction, verbal cueing, education on general use of comfort measures and self massage techniques (such as application of heat or cold and electrical stimulation if appropriate), and education related to topics regarding general health and wellness. I understand that this workshop is being provided in a virtual format; I acknowledge that I am responsible for ensuring the safety of the space in which I will be participating in the workshop. In addition, I authorize Alexandra Randolph Courts to perform the following instruction, treatments and/or procedures related to any follow-up wellness visits: individual health and wellness coaching and exercise instruction. I understand that these procedures are being performed to: improve physical function and mobility, reduce pain, and improve health and wellness. Furthermore, I am voluntarily participating in this workshop and acknowledge that it involves physical exertion. I understand that the instructor’s role is to provide instruction and not supervision. I acknowledge that I am responsible for monitoring my own response to exercise and adjusting to a level that fits my abilities. The risks associated with the above mentioned procedures include but are not limited to: soreness, stiffness, fatigue, pain, bruising, swelling, injury, increasing risk of sudden cardiac arrest with vigorous exercise in those with cardiovascular disease. I fully understand the nature and purposes of the above mentioned procedures.
Limitations on Authorization
2. This authorization does not extend to the performance of the following treatments and/or procedures: physical therapy for the treatment of a specific injury or impairment. Wellness services are intended for the purpose of fitness, prevention and performance.
Expansion of Authorization
3. During the course of my fitness, wellness, and preventative services, I understand that unforeseen conditions and/or complications may arise or be discovered which require additional or different treatments and/or procedures than those specifically consented to above. Therefore, I further authorize the above named instructor, and such other assistants or designees as may be selected by the instructor who is to perform the procedure or treatment, to perform such other procedures as may be medically necessary and advisable in his or her best professional judgment.
Disclaimer of Particular Result
4. I am aware that the practice of physical fitness and wellness instruction is not an exact science and that the response to instruction can vary widely from person to person and that no guarantees can be or have been made to me concerning the outcomes and/or results of my instruction.
Liability Waiver Release
5. I acknowledge that I am responsible for consulting with my healthcare provider prior to and regarding my participation in this workshop. I declare that I have no medical condition that would prohibit me from participation in this workshop. I agree to assume full responsibility for any injuries, damages or risks known or unknown that may occur due to my participation in this workshop.
5. I hereby acknowledge that I have been informed of the nature, purpose, risks, and expected results of this instruction and my participation in this workshop. I acknowledge that the content of this workshop should not be construed as giving specific medical advice and all specific medical advice is deferred to the client’s physician/provider. All of my questions regarding these treatments and procedures have been answered in a satisfactory manner. I have read and understand this agreement. I realize that by signing this informed consent I am consenting to the performance of the instruction, treatments and procedures noted herein. Furthermore, I am aware that I have a right to withdraw my consent to any of the above-mentioned instruction, treatments and procedures at any time before or during the workshop. I further acknowledge that by typing my name, this is considered a legal and binding document.
Please sign by typing your name when prompted in the registration section on the Eventbrite Site.