Voluntary Assumption of Risk and Waiver of Liability Relating to Coronavirus/COVID-19 (this “Voluntary Waiver and Consent”)
The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have at times, in many locations, prohibited the congregation of groups of people.
Our operations at Ohashi Performance in Motion Rehabilitation, Ltd (dba: Performance in Motion) naturally expose all of us (including, without limitation, our patients and staff and, to some extent, those each of the foregoing may come into contact with) to risks associated with public health crises and pandemics, such as the outbreak of COVID-19. As a result, Performance in Motion has put in place preventative measures to reduce the spread of COVID-19; however, it is impossible for anyone (including, without limitation, patients and staff of Performance in Motion) to guarantee that neither you, any member of your family nor anyone you may come in contact with after spending any time at Performance in Motion, as a result of spending any time at Performance in Motion, will be exposed to COVID-19.
BY SIGNING THIS VOLUNTARY WAIVER AND CONSENT, I HEREBY KNOWINGLY, INTENTIONALLY, VOLUNTARILY, INTELLIGENTLY AND UNCONDITIONALLY: (1) AGREE AND ACKNOWLEDGE THE CONTAGIOUS NATURE OF COVID-19; (2) ASSUME ANY RISK THAT I MAY BE EXPOSED TO, DIRECTLY OR INDIRECTLY, WITH RESPECT TO COVID-19 AS RESULT OF SPENDING ANY TIME WITHIN PERFORMANCE IN MOTION; AND (3) AGREE AND ACKNOWLEDGE ANY SUCH EXPOSURE MAY RESULT IN PERSONAL INJURY, ILLNESS, PERMANENT DISABILITY, AND POSSIBLY DEATH. I UNDERSTAND THE RISK OF BECOMING EXPOSED TO, OR POSSIBLY INFECTED BY COVID-19, AS A RESULT OF SPENDING ANY AMOUNT OF TIME AT PERFORMANCE IN MOTION, MAY, DIRECTLY OR INDIRECTLY, RESULT FROM THE ACTIONS, OMISSIONS OR NEGLIGENCE OF MYSELF AND/OR ANY OTHER PERSON INCLUDING, BUT NOT LIMITED TO, ANY PATIENT OR ANY MEMBER OF THE STAFF, AND BY SIGNING BELOW, AGREE TO ANY AND ALL RISK WITH RESPECT TO ANY OF THE FOREGOING.
I hereby certify to Performance in Motion that:
1. I have not had a fever, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea in the last 72 hours.
2. In the last 10 days I have not been diagnosed with or been in close contact with someone who has been diagnosed with COVID-19, has had COVID-19 symptoms, or has had a positive or pending COVID-19 test.
I hereby, on behalf of myself and on behalf of all of my past, present and future agents, representatives, attorneys, partners, insurers, assigns and lien holders, heirs and executors and all others acting by, through or in concert with any of the foregoing (collectively, “Releasors”), hereby release acquit and forever discharge Performance in Motion, Robbie Ohashi, Jacob Brueck, Jyron Aparri, Jennifer Ohashi, Autumn Neuharth, Taylor Reid and any of their past, present and future agents, patients, employees, representatives, attorneys, partners, insurers, successors, heirs and executors and all others acting by, through or in concert with any of the foregoing (collectively, the “Released Parties”) from all liability, rights, claims, and demands, including but not limited to damages, costs, medical costs, expenses, actions, causes of action, suits of liability, wrongful death, survival actions, and controversies of any and every kind and description whatsoever, whether at law or equity, under statute, in contract, or in tort, suspected or unsuspected, known or unknown, without exception or reservation, now existing or which may accrue later, including any related, directly or directly, to COVID-19 (each, a “Claim” and collectively, the “Claims”).
I hereby further agree to indemnify and hold harmless the Released Parties, and any of them, from each Claim and any and all Claims.
I represent and warrant to Performance in Motion that I have had the opportunity to obtain and receive independent legal advice from an attorney of my choosing, or that I have KNOWINGLY, INTENTIONALLY, VOLUNTARILY, INTELLIGENTLY AND UNCONDITIONALLY waived seeking such advice of counsel, with respect to the legal effect of this Voluntary Waiver and Consent, and further represent and warrant to Performance in Motion that I have carefully reviewed this Voluntary Waiver and Consent and that I understand each and every term hereof.
*Print Patient/Client Name:
Signature of Patient (Guardian's signature if Minor) Below:
COVID-19 Vaccination Declaration Form
I declare that I am fully vaccinated for Covid-19 as it has been 2 weeks after my second dose in a 2-dose series, such as the Pfizer or Moderna vaccines, or 2 weeks after a single-dose vaccine, such as Johnson & Johnson's Janssen vaccine.
Decline to respond
The above information is true to the best of my knowledge.
*Print Patient/Client Name:
Signature of Patient (Guardian's signature if Minor) Below:
RELEASE AND WAIVER OF LIABILITY
I understand that this Release And Waiver Of Liability governs all rights and liabilities relating in any way to the receipt by me from Performance in Motion Rehabilitation, Inc. and/or its agents of Services, as that term is defined below. I have read, understand, and agree to be bound by the terms below.
“Services” shall mean any and all manner of goods and services offered by Performance in Motion or any other Released Party to you. These services, which may take the form of training, treatment, consulting, and the like, expressly include but are not limited to: evaluations; rehabilitation; reconditioning; performance planning; performance training (including strength & conditioning training, speed& quickness training, plyometric training, and the like); recovery and regeneration training; sports nutrition consultation; supplement and nutrition provision; any consultation related to any item in this list; injury reduction and treatment; technical and tactical instruction; performance enhancement.
“Training” shall mean any act, omission, or other activity required of you or carried out by you in relation to the Services. This term shall not be limited, in any way, with respect to any location site, or facility at which any activities related to the Services takes place.
“Released Parties” shall mean Robbie Ohashi, Jennifer Ohashi, Jacob Brueck, Jyron Aparri, Alex Autumn Neuharth, Performance in Motion, along with, in relation to the previously-listed respective Released Parties, all of their officers, directors, shareholders, insurers, partners, employees, employers, agents, successors, contractors, assigns, affiliates, parent corporations, affiliated corporations, and subsidiary corporations.
Terms and Provisions
The risk of injury from participation in sporting events and other strenuous physical activity, including Training, is significant, including the potential for permanent paralysis, other serious injury, and/or death. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS of participation in Training, including, without limitation, risk arising from or relating in any way to the condition of the facilities, equipment, fields, and surrounding premises, the actions of persons other than myself, my own actions, and travel to and from the Training (including, but not limited to, travel services provided by any Released Party or in any vehicle owned, operated, or associated with any Released Party). I UNDERSTAND THAT THERE LEASED PARTIES MAKE NO WARRANTIES and shall in no event be responsible or liable for the defective or dangerous condition of the facilities, equipment, fields, and surrounding premises, except to the extent such condition(s) result(s) solely from the gross negligence or willful misconduct of a Released Party.
I AGREE THAT THERE LEASED PARTIES SHALL NOT BE LIABLE for any claims, demands, injuries, damages, actions, or causes of action that arise in whole or in part due to the negligence of the Released Parties, or any of them. FURTHERMORE, I FOREVER RELEASE AND DISCHARGE, AND AGREE TO INDEMNIFY AND HOLD HARMLESS, the Released Parties from and in relation to all claims, demands, injuries, damages, actions, or causes of action that arise from or relate in any way to my participation in the Training, other than such claims, demands, etc. that arise solely from the gross negligence or willful misconduct of a Released Party. I FURTHER WARRANT AND CERTIFY that I have no health conditions or defects that would prevent me from participating safely in the Training, that I have taken every reasonable act necessary to make this warranty and certification in relation to such participation, and that I am otherwise sufficiently fit and healthy to so participate.
I WARRANT AND UNDERSTAND that it is my sole and personal responsibility to obtain insurance to compensate for any and all injuries which might arise from my participation in the Training, and furthermore agree to look solely to such insurance to cover losses resulting from any injuries, regardless of fault, and waive all rights of subrogation on behalf of any and all Released Parties which may now or ever exist as a result of such insurance.
I agree that I will be solely responsible for any damage (whether to a person or property) I, my guests, agents or invitees cause, including but not limited to any Performance in Motion equipment or personnel and any hotel property or personnel, and will indemnify Performance in Motion, Inc. in connection with any claims, suits, damages, costs, lawsuits, fines, penalties, liabilities, expenses (including attorneys’ fees and costs) and other obligations directly or indirectly arising out of or related to any act or omission by me, my guests,agents or invitees.
IN ANY EVENT, THE LIABILITY OF A RELEASED PARTY TO ME FOR ANY REASON AND UPON ANY CAUSE OF ACTION SHALL NOT EXCEED THE AMOUNT ACTUALLY PAID BY ME TO PERFORMANCE IN MOTION, INC DURING THE TWELVE MONTHS IMMEDIATELY PRECEDING MY ASSERTION OF SUCH CLAIM. THIS LIMITATION APPLIES TO ALL CAUSES OF ACTION IN THE AGGREGATE, INCLUDING, WITHOUT LIMITATION TO EQUITY, BREACH OF CONTRACT, BREACH OF WARRANTY, NEGLIGENCE, STRICT LIABILITY, MISREPRESENTATIONS, AND OTHER TORTS.
If any paragraph, subparagraph, sentence or clause of this Agreement shall be adjudged illegal, invalid or unenforceable, the balance of the Agreement shall remain in full force and effect. This Agreement shall be construed and interpreted under Illinois law. Any lawsuit or claim arising from or relating in any way to Training, Services, and/or this Agreement shall be brought, if at all, in Cook County, Illinois.
I have read this Agreement, fully understand its terms, understand that I have given up substantial rights by signing it,and sign it freely and voluntarily. I acknowledge that I have received valuable consideration in relation to my execution of this Agreement, which I understand to be a prerequisite to my receipt of Services. Finally, I understand that this Agreement shall be of full force and effect as to any and all Services I receive from the Released Parties, without regard to the date or timing of such service.
Patient or Parent/Legal Guardian Name:
Signature (Guardians signature if minor):
CONSENT TO TREAT
I understand that I may require some form of rehabilitative or preventative treatment during my stay at Performance in Motion. I also could be referred for rehabilitative treatment to Performance in Motion via a referral from a physician. In such cases, an individual treatment plan will be described for me. I understand that I have the right to ask and have any questions answered prior to receiving any treatment, including any risks or alternatives to the treatment plan that has been prescribed by my physician and/or recommended by my therapist. By signing this agreement, I consent to have Performance in Motion provide treatment and care as necessary for rehabilitation of an injury or injury prevention. The statements are true and complete to the best of my knowledge.