Stretch Waiver Questionnaire
First Name
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Email
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Phone
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Date
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Do you currently have any pain associated with the areas you want to stretch? (Yes or no, if yes, please elaborate)
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Are you currently seeing a physician regarding your pain? (Yes or no, if yes, please provide physician info)
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What is your goal from your stretching sessions?
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I acknowledge that I have chosen to receive stretching services from an independent contractor or employee with THE FITSMITH, INC. (which herein shall include all of its owners, members, managers, officers, principals, independent contractors, and employees). I have observed and I am aware of the nature and possible intensity of the stretching programs offered by THE FITSMITH, INC.. I recognize and understand that, while unlikely, my participation may result in physical harm (which could require medical attention and hospitalization) including without limitation muscular damage, skeletal damage or nerve damage. I willingly assume full responsibility for any and all risks that I am exposing myself to as a result of my being stretched at THE FITSMITH, INC. By assuming these risks, I understand that I am waiving claims I may otherwise have had. Health Risks: I hereby warrant that I know of no medical problems that would put me at an increased risk of injury as a result of receiving a stretch. I further warrant that I have not made THE FITSMITH, INC aware of any reason why I am unfit to receive their offered services. Reasons why I may be unfit to receive a stretch include, but are not limited to, muscular damage, skeletal damage, nerve damage. Release: In full consideration of the above mentioned risks and hazards and in full consideration of the fact that I am willingly and voluntarily accepting the services offered by THE FITSMITH, INC, and with my full understanding of all of the above, I voluntarily waive, release, discharge, and hold harmless THE FITSMITH, INC of any and all liability, claims, demands, actions, causes of action, rights of action, and/or damages of any kind related to, arising from, or in any way connected with, my receiving stretching services offered by THE FITSMITH, INC, including those allegedly attributed to the negligent acts or omissions of the above mentioned parties. In signing this document, I fully recognize and understand that if I am hurt, I am giving up my right to make a claim or file a lawsuit against THE FITSMITH, INC even if they negligently or by some other act or omission cause the injury or damage. THIS SHALL REMAIN IN EFFECT FOR FUTURE VISITS UNLESS & UNTIL REVOKED I have read this document in its entirety. I fully understand the foregoing assumption of risk and release of liability, and all terms and conditions contained herein, and I understand that by signing below I have released any and all claims against THE FITSMITH, INC and its owners, members, managers, affiliates, agents, officers, principals, independent contractors, and employees. I understand that by voluntarily signing this form I am waiving valuable legal rights. This agreement shall be binding upon me, my successors, representatives, heirs, executors, assigns and transferees. If any portion of this agreement is held invalid, I agree that the remainder of the agreement shall remain in full legal force and effect.
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