Medical Questionnaire

Please fill out the following form to help us understand your physical condition.

Have you been hospitalized in the last 12 months?
Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?
Do you feel pain in your chest when you perform physical activity?
In the past month, have you had chest pain when you were not performing any physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?
Do you know of any other reason why you should not engage in physical activity?

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COVID-19 WAIVER

Fitpattern LLC,  Client Waiver

COVID-19 WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT

IN CONSIDERATION for being permitted to participate in the physical fitness training session provided by FItpattern LLC, I, on behalf of myself and all persons and entities claiming by, through or under me hereby acknowledge, agree and represent that I have inspected and carefully considered Fitpattern, the Fitpattern premises, equipment and facilities, and I find and accept the same as being safe and reasonably suited for my use and/or participation in classes provided at the this location.

I acknowledge that the novel coronavirus (“COVID-19”) is a global pandemic and that infections have been confirmed throughout the United States and internationally, including in the state in which this class is located. I further understand and acknowledge that the President of the United States declared that the outbreak of COVID-19 in the United States constitutes a national emergency.

 

I understand and acknowledge that Fitpattern, LLC. cannot guarantee my safety or immunity from infection. The mode by which COVID-19 is transmitted or how long it remains on surfaces or in the air is not entirely known. I fully understand, acknowledge and appreciate these facts and the uncertainty of the virus and how it may impact my health.  I knowingly and voluntarily assume all risks associated directly or indirectly with participating in any activity at Fitpattern LLC, including classes, traveling to and from Fitpattern, entering and existing the Fitpattern premises, using equipment at Fitpattern, interacting with other persons at or around Fitpattern, and/or using facilities within the Fitpattern premises, including restrooms (collectively, the “Voluntary Activity”).  With this understanding, I knowingly and voluntarily waive and release Fitpattern LLC, and/or their respective directors, officers, employees, volunteers and agents (collectively, the “Releasees”), from any and all present and future claims of any type, including for any harm or loss, economic loss, personal injury, disease, death and property damage suffered by me. I agree to indemnify and hold harmless, and covenant not to sue, the Releases for any personal injury, death, medical expenses, disability, loss of capacity, property damage, court costs, attorneys’ fees, and/or other loss, including arising out of or related, whether directly or indirectly, to any Voluntary Activity.

I represent and attest that:

1.      I am not experiencing any symptoms of illness. I do not have a fever or cough and am not experiencing shortness of breath. If I develop any of these symptoms, or if I have a suspected or diagnosed case of COVID-19, I agree that I will not attend or participate in any class Fitpattern, or otherwise enter or be physically present at Fitpattern.

2.      I agree to follow any and all safety protocols that have been or will be implemented by Fitpattern, including those that are posted at Fitpattern and those that are sent to me electronically including by text message, SMS and/or email, as well as those posted on the website for Fitpattern. I acknowledge that Fitpattern LLC., may change these protocols at any time and I agree to abide by any and all such changes.

3.      I do not believe that I have been exposed to a person with a confirmed or suspected case of COVID-19.

4.      I have not been diagnosed with COVID-19 and not yet cleared as non-contagious by state or local public health authorities.

5.      I am and will continue to follow recommended guidelines as much as possible, including practicing social distancing, trying to maintain separation of six feet from others and otherwise limiting by exposure to COVID-19.

6.      I will not visit or use Fitpattern services or the Fitpattern facilities, services and/or programs of Fitpattern within 14 days after (i) returning from a highly impacted area subject to a CDC Level 3 Travel Health Notice, (ii) exposure to any person returning from areas subject to a CDC Level 3 Travel Health Notice, and/or (iii) exposure to any person who has a suspected or confirmed case of COVID-19. I agree to regularly check the CDC Travel Health Notices including those listed at the following site: (https://www.cdc.gov/coronavirus/2019-ncov/travelers/index.html) before attending classes at Fitpattern.

7.      I agree to notify the staff of Fitpattern immediately if I believe that I am experiencing any symptoms of COVID-19 and/or if I have a suspected or diagnosed case of COVID-19.

 

I fully understand and appreciate both the known and potential dangers of using Fitpattern, its facilities, equipment, services and programs and acknowledge that the use thereof by me may, despite the Fitpattern LLC’s reasonable efforts to mitigate such dangers, result in exposure to COVID-19, which could result in quarantine requirements, serious illness, disability and/or death.

 

I agree and acknowledge that use of Fitpattern and its facilities and services may involve inherent danger and risk, including, without limitation, the risk of physical illness or injury, death and/or property damage. I HEREBY ASSUME FULL RESPONSIBILITY FOR, AND RISK OF ILLNESS, BODILY INJURY DEATH OR PROPERTY DAMAGE to me, including due to negligence, active or passive, or otherwise while in, about or upon the premises of the Outlet and/or while using the premises or any facilities or equipment thereon or participating in any program affiliated with Fitpattern. I acknowledge that any illness or injuries that I contract or sustain may be compounded by negligent first aid or emergency response of the Releasees and I waive any claim in respect thereof.

 

I further expressly agree that the foregoing COVID-19 WAIVER OF LIABILITY, ASSUMPTION OF RISK, RELEASE AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as is permitted by applicable law and that if any portion thereof is held invalid, it is agreed that the balance will, notwithstanding, continue in full legal force and effect.

 

I HAVE CAREFULLY READ AND VOLUNTARILY SIGN THIS ASSUMPTION OF RISK, RELEASE AND WAIVER OF LIABILITY, AND INDEMNITY AGREEMENT AND FURTHER AGREE THAT NO ORAL REPRESENTATIONS, STATEMENTS OR INDUCEMENT APART FROM THE FOREGOING WRITTEN AGREEMENT HAVE BEEN MADE. I AM AWARE THAT BY AGREEING TO THIS AGREEMENT I AM GIVING UP VALUABLE LEGAL RIGHTS INCLUDING THE RIGHT TO RECOVER DAMAGES FROM THE RELEASES IN CASE OF ILLNESS, INJURY , DEATH OR PROPERTY LOSS OR DAMAGES, INCLUDING, FOR THE AVOIDANCE OF DOUBT AND WITHOUT LIMITATION, EXPOSURE TO COVID -19 AT ANY OUTLET OR PROGRAM AND ALL ILLNESS, INJURY OR DEATH RESULTING THEREFROM.  I UNDERSTAND THAT THIS DOCUMENT IS A PROMISE NOT TO SUE AND A RELEASE OF AND INDEMNIFICATION FOR ALL CLAIMS AND IS BINDING ON ME, MY HEIRS, FAMILY, ESTATE, REPRESENTATIVES AND ASSIGNS.

I HAVE READ AND UNDERSTAND THE TERMS OF THIS ASSUMPTION OF RISK, RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT AND AGREE TO ITS TERMS.

TWO DONE ONE LEFT!

Fit Pattern Waiver

Fitpattern LLC member/participant acknowledgment, assumption of risk, full release from liability, and image and video release

 

In consideration of the services of Fitpattern LLC,  I hereby agree, on behalf of myself and my employees, agents, representatives, guardians, successors, children, heirs, assigns, next of kin, personal representatives, and estate (the “Related Parties”), to release, indemnify, and discharge Fitpattern LLC, its agents, members, manager, officers, volunteers, participants, employees, independent contractors, and all other persons or entities acting in any capacity on its behalf (hereinafter collectively referred to as "Fitpattern"), as follows:

I acknowledge that my participation in Fitpattern’s activities involves the inherent risk of physical injuries or other damages, including but not limited to: heart attacks, muscle strains, pulls or tears, broken bones, shin splints, heart prostration, knee/lower back/foot injuries and any other illness, soreness or injury however caused, occurring during or after participant participation in the activities. I further acknowledge that such risks include, but are not limited to, injuries caused by the active or passive negligence of Fitpattern, defective or improperly used equipment, over-exertion by me, slip and fall by me, or an unknown health problem of mine. 

I expressly assume all risk and responsibility that may result from my participation in Fitpattern’s programs and physical activities. My participation in these activities is purely voluntary, and I elect to participate with knowledge of the risks. I affirm that I am in good physical condition and do not suffer from any disability that would prevent or limit participation in the physical activities. I acknowledge that participation will be physically and mentally challenging, and I agree that it is my responsibility to seek competent medical or other professional advice, regarding any concerns or questions involved with my ability to take part in Innate activities. By agreeing to this statement, I assert that I am capable of participating in the physical activities. I agree to assume all risk and responsibility for not exceeding my physical limits. 

I hereby voluntarily release and indemnify Fitpattern from any and all liability to me and the Related Parties for all claims, damage, demands, or causes of action for personal injury, death, or property damage, which are in any way connected with my participation in Fitpattern’s programs or my use of Fitpattern’s equipment or facilities. This release includes, without limitation, any personal injury, death, or property damage caused by the active or passive negligence of Innate. I agree to bear sole responsibility for any loss. 

I understand and acknowledge that this release of liability applies to and includes all unknown or unsuspected consequences or results arising from or relating to my participation in Fitpattern’s programs.

I also give Fitpattern LLC permission to interview me and/or to use my name, image, likeness, and voice in photos, slides, video, voice recorded productions, radio coverage, television coverage and/or any other media, now and in the future, in perpetuity, for the purpose of promoting, advertising, and marketing Fitpattern LLC, and for other use by Fitpattern LLC. I will make no monetary or other claim against Fitpattern LLC for such use. 

 

By signing this document, I acknowledge that if anyone is hurt or property is damaged during my participation in this activity, I may be found by a court of law to have waived my right to maintain a lawsuit against Fitpattern LLC,  on the basis of any claim from which I have released them herein. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect.         

 

I have had sufficient opportunity to read this entire document.  I have read and understood it, and I agree to be bound by its terms.  I acknowledge that Innate is materially relying on this waiver in allowing me to engage in its programs and use its facilities.