Due To The COVID-19 Outbreak, Nourish Wellness Path Is Taking Extra Precautions With The Care And Consideration Of Every Patient/Student’s Health In Accordance With The Guidelines Set Forth By Federal, State, And Local Health Agencies.
COVID Symptoms include:
- Dry Cough
- Difficulty Breathing
- I agree to the following:
- I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above WITHIN THE LAST 14 DAYS.
- I affirm that I, as well as all household members, have not been diagnosed with COVID-19 WITHIN THE PAST 30 DAYS.
- I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 WITHIN THE PAST 30 DAYS.
- I affirm that I, as well as all household members, have not traveled outside of the country, or to any city considered to be a “hot spot” for COVID-19 infections WITHIN THE PAST 30 DAYS.
- I understand that Nourish Wellness Path cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each client.
- In consideration of and as an express condition to my participation in any Activity with Nourish Wellness Path, now and in the future, I represent and agree as follows:
- I have been examined by a licensed physician, am in good physical health, and do not suffer from any medical condition which would limit my participation in the classes, programs or workshops (“Activities”) offered by Nourish Wellness Path. I understand and voluntarily assume complete responsibility for all risks, injuries and/or damages which may occur in connection with my participation in the Activities, which include but are not limited to, personal injury, bodily injury, disease, disability, death, humiliation, any other direct loss or consequential loss of any kind arising in connection with my participation in the Activities (“Risks”). If I am pregnant, I will not participate in the Activities until I have discussed the potential risks with my obstetrician. I agree to follow my obstetrician’s recommendation and on behalf of myself, my heirs, my spouse or any other interested party agree to indemnify and hold Nourish Wellness Path, its owners, officers, affiliates, employees and instructors harmless for any possible injury to myself or unborn child.
- I hereby WAIVE AND RELEASE Nourish Wellness Path from any claim, demand, cause of action of any kind resulting from or related to my participation in the Activities. I further recognize that use of the facility includes Risks, whether caused by myself or someone else, and agree to INDEMNIFY, DEFEND AND HOLD HARMLESS Nourish Wellness Path from any loss as a result of my use of or presence on the facilities. I understand and agree that I alone am responsible for my personal property and agree to hold Nourish Wellness Path harmless for any damage to or theft of personal property.
If I am under the age of 18, I will disclose this information to an employee of Nourish Wellness Path, will provide my signature, and my parent or legal guardian’s signature on this Agreement prior to participation in any Activity. If I am under the age of 16 I will notify an employee of Nourish Wellness Path and will not participate in any heated classes such as hot yoga, by way of example. No interpretation shall be made for or against a party by reason of authorship and any ambiguity shall be resolved so as to reflect the intent of this Agreement as closely as possible.
- Your Name / Name of Parent or Legal Guardian (if applicable)*
- By printing your name here, you are indicating the authorized use of your electronic signature in signing this Agreement of Release and Waiver of Liability.