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Complete this form if:
You are a member in need of a valid waiver on file.
You are a member who needs to update their information on file.
You are a member and need to add minors to your membership.
Personal Information
Emergency Contact
Health Information
Sauna Use
Red Light Therapy Use
Memberships are a 12-month obligation. *
You may pause any membership for two (2) months with documentation of hardship.*
You may cancel any membership early with a written notice. A membership cancellation invoice of $25 will be sent via email and will serve as your 30-day notice once payment is received. The membership cancellation process will not be finalized until the $25 emailed invoice is paid. If you choose to cancel after your 12-month obligatory period, a cancellation fee of $25 will not be charged. *
Memberships paid in full one year in advance at reduced rates are non-refundable. *
Membership upgrades will occur on the very next billing cycle. Downgrades will have a 30-day notice policy, meaning the downgrade will occur on the second cycle after notice is given. *
Acknowledgment of Risks and Waiver of Liability - DW
Risk Acknowledgement: I understand that health or fitness club activities involve known and unanticipated risks which could result in physical or emotional injury, paralysis or permanent disability, death, and property damage.*
Risks include, but are not limited to: musculoskeletal injuries, broken bones, and/or overuse injuries, injuries caused by equipment that breaks or otherwise fails, death as a result of drowning or brain damage caused by near drowning; medical conditions resulting from physical activity, and damaged clothing or other property. I understand such risks simply cannot be eliminated, despite the use of safety equipment, without jeopardizing the essential qualities of the activity.*
Assumption of Risk: I acknowledge and expressly accept and assume all of the risks inherent in this activity or that might have been caused by the negligence of the Releasees. My participation in this activity is purely voluntary and I elect to participate despite the risks. In addition, if at any time I believe that event conditions are unsafe or that I am unable to participate due to physical or medical conditions, then I will immediately discontinue participation.*
Open Gym 24/7 & Pilates on Demand Access: I understand that I am using a 24/7 facility and there will be no supervision or assistance during my workout, especially outside of staffed hours. *
Waiver of Liability: I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless Releasees from any and all claims, demands, or causes of action which are in any way connected with my participation in this activity, or my use of their equipment or facilities, arising from negligence. This release does not apply to claims arising from intentional conduct. *
Attorney Fees: Should Releasees or anyone acting on their behalf be required to incur attorney's fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs.*
Insurance: I represent that I have adequate insurance to cover any injury or damage I may suffer or cause while participating in this activity, or else I agree to bear the costs of such injury or damage myself. I further represent that I have no medical or physical condition which could interfere with my safety in this activity, or else I am willing to assume - and bear the costs of - all risks that may be created, directly or indirectly, by any such condition.*
Lawsuits: In the event that I file a lawsuit, I agree to do so solely in the state wnere Releasees' facility is located, and I further agree that the substantive law of that state shall apply.*
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.*
By signing this document, I agree that if I am hurt or my property is damaged during my participation in this activity, then I may be found by a court of law to have waived my right to maintain a lawsuit against the parties being released on the basis of any claim for negligence.*
I have had sufficient time to read this entire document and, should I choose to do so, consult with legal counsel prior to signing. Also, I understand that this activity might not be made available to me or that the cost to engage in this activity would be significantly greater if I were to choose not to sign this release, and agree that the opportunity to participate at the stated cost in return for the execution of this release is a reasonable bargain.*
Acknowledgment Of Risks and Waiver of Liability Infrared Sauna & Red Light Therapy
Health problems that are contraindicated for Infrared Sauna Use:
Pregnancy
Cardiovascular Issues (Like Heart Failure, Hypertension)
Fever/Infection
Acute Joint Injuries
Bleeding Disorders
Impaired Sweating (MS, Diabetes With Neuropathy)
Being Under the Influence of Alcohol/Drugs
**If you have any of the above health related problems, you are not a good candidate for infrared sauna use and will need to be cleared by a medical professional before being able to participate.
Health problems that are contraindicated for Red Light Therapy:
Malignant Cancers
Eye Diseases
Recent Burns
Light Sensitivity
Hyperthyroidism
Epilepsy
Systemic Lupus Erythematosus (SLE)
Severe Blood Loss/Bleeding
Heart Disease or Pacemaker
Use of Photosensitizing Medications
**If you have any of the above health related problems, you are not a good candidate for red light therapy and will need to be cleared by a medical professional before being able to participate.
Risk Acknowledgment: I understand that using an infrared sauna and/or red light therapy may pose health risks, especially for
individuals with certain medical conditions. I have informed DW staff of all relevant health issues and have consulted a healthcare professional when necessary before deciding to use the sauna and/or red light therapy.*
Assumption of Risk (Infrared Sauna): I acknowledge and voluntarily assume the risks associated with sauna use, understanding that there is a possibility of adverse physical effects, including but not limited to dehydration, fainting, heat stroke, or heart failure.*
Assumption of Risk (Red Light Therapy): I acknowledge and voluntarily assume the risks associated with red light therapy use, understanding that there is a possibility of adverse physical effects, including but not limited to eye damage, skin irritation, and burns.*
Waiver of Liability: I hereby agree to release, waive, discharge, and covenant not to sue the facility, its officers, employees, or agents from any and all liabilities arising from bodily injury, accidents, or death that may occur as a result of my participation in sauna and/or red light therapy activities. This release extends to all claims of every kind or nature whatsoever, foreseen or unforeseen, known or unknown.*
Emergency Procedures: I agree to immediately report any feelings of discomfort, dizziness, or other concerning symptoms to the staff and cease using the sauna and/or red light therapy if advised by staff or if such symptoms occur.*
Privacy Acknowledgement
Confidentiality Commitment: I acknowledge that the sauna and red light therapy facility commits to maintaining the confidentiality and privacy of all personal and health information provided in this form. Information will only be used to evaluate suitability for sauna and/or red light therapy use and manage my experiences appropriately.*
Data Usage: I consent to the collection, use, and, where necessary, the disclosure of my personal information as needed for the provision of sauna and/or red light therapy services. This may include sharing information with healthcare professionals under circumstances that require medical intervention.*
Rights to Access and Correction: I understand that I have the right to request access to my personal records held by the facility and can request corrections to any inaccuracies in my personal data.*
Security Measures: I acknowledge that the facility implements appropriate security measures to protect my personal data from unauthorized access, alteration, or destruction.*
(Must be completed for participants under the age of 18)
In consideration of minor being permitted to participate in this activity, I further agree to indemnify and hold harmless Releasees from any claims alleging negligence which are brought by or on behalf of minor or are in any way connected with such participation by minor.
31 W Church Street
Newark, OH 43055
(740) 280-2031
lcdestinationwellness@gmail.com
www.lcsdestinationwellness.com