Please read the following release form carefully, then Sign & Submit below:
I wish to participate in the health program offered by Mosaic Health. I understand there are inherent risks in participating in a program of strenuous exercise. Consequently, I have been examined by a physician of my choice and have obtained his/her approval for my participation in a fitness program within sixty (60) days of the date set forth below. No change has occurred in my physical condition since the date such approval was given which might affect my ability to participate in the health program. If a physician has not examined me, I agree to see a physician within sixty (60) days of the date set forth below to obtain his/her approval for my participation in a health program. I agree that Mosaic Health shall not be liable or responsible for any injuries to me resulting from my participation in the health program and I expressly release and discharge Mosaic Health from all claims, actions, judgments and the like which I may have or claim to have as a result of any injury or other damage which may occur in connection with my participation in the health program, excepting only an injury caused by the gross negligence or intentional act of such person or persons.
I certify that the answers to the questions outlined on the Health Assessment form are true and complete to the best of my knowledge. I acknowledge that medical clearance has been attained. I understand and agree that it is my responsibility to inform Mosaic Health of any conditions or changes in my health, now and on going, which might affect my ability to exercise safely and with minimal risk of injury.
I understand that I am not obligated to perform nor participate in any activity that I do not wish to do, and that it is my right to refuse such participation at any time during my training sessions. I understand that should I feel lightheaded, faint, dizzy, nauseated, or experience pain or discomfort, I am to stop the activity and inform my Personal Trainer.
I understand the results of any health program cannot be guaranteed and my progress depends on my effort and cooperation in and outside of the sessions.
I understand that all personal training sessions are 40 minutes in length.
I understand that Mosaic Health requires payment for each monthly program in advance of the first session of each month. Once my trainer and I have decided upon the monthly schedule, payment must be made before the sessions are conducted. I understand that all Personal Training sessions are non-transferable and non-refundable.
I understand that I have enrolled in a monthly health program and it is my responsibility to attend every scheduled session. If I fail to attend any scheduled session for the month I forfeit any opportunity to reschedule that session.
I understand that the usage of any nutritional supplements is done under my own will and has not been prescribed by Mosaic Health.
I understand that should my Personal Trainer become ill, away on holidays or absent for any reason, all appropriate sessions will be rescheduled.
I hereby give my consent to Mosaic Health to use my image and likeness in its publications, advertising or other media activities (including the Internet). This consent includes, but is not limited to: (a) Permission to photograph, film, or otherwise make a video reproduction of me and/or record my voice; (b) Permission to use my name; and (c) Permission to use quotes (or excerpts of such quotes), in part or in whole, in its publications, and electronic media (including the Internet).