ࡱ > h k g bjbj>> T T z f , , | | | 8 $ % L T T T b% d% d% d% d% d% d% $ ' M* b % | " % , , T T 8 % R R R ^ , 8 T | T b% R b% R R r " T d # T il ^ F# N% % 0 % T# * j * # * | # \ R % % R % * : MEMBER WAIVER PLEASE READ CAREFULLY! THIS IS A LEGAL DOCUMENT, WHICH AFFECTS YOUR LEGAL RIGHTS! WAIVER AND RELEASE OF LIABILITY ASSUMPTION OF RISK AND INDEMNITY AGREEMENT I __________________________________, in consideration of being permitted to use the Fit for Life Facility including all equipment, state and agree as follows on behalf of myself and my personal representatives, next of kin, heirs, executors, administrators, agents, and assigns: I understand that any physical exercise or activity involves the risk of bodily injury, including permanent disability, paralysis, and death. I understand that such injury may be caused by my own actions or inactions, or the actions or inactions of others. I agree to engage in any physical exercise or activity and to use the facility at my own risk. This includes, but is not limited to, the following: (a) my use of the parking area, sidewalk, equipment, and any other amenity in the facility; (b) my participation in any activity in the facility; and (c) use of any information, instruction, advice, example, direction, or suggestion I receive through any means while at the Fit for Life facility. I agree that I am voluntarily engaging in these activities and using the facilities, equipment, and amenities. I assume all risk of injury, illness, damage, or loss of any kind resulting from such activities and usage, including, but not limited to, any loss or theft of personal property. I agree to release and discharge Logan County Hospital, (and its affiliates, employees, agents, representatives, successors, and assigns) to the fullest extent permitted by law, from any and all claims or causes of action (known or unknown) arising out of any negligence on the part of LCH. If, despite this agreement, I, or anyone on my behalf, makes a claim against LCH, I will indemnify, save, and hold harmless LCH from any litigation expense, attorney fees, loss, liability, damage, or cost LCH may incur as a result of such claim. NAME______________________________________________________________________________ ADDRESS___________________________________________________________________________ CITY / STATE / ZIP_____________________________________________________________________ HOME PHONE_____________________________DATE OF BIRTH_____________________________ I have read this agreement and fully understand its terms. I have had an opportunity to ask any questions I may have concerning this agreement, and all such questions have been answered to my satisfaction. I understand that this agreement cannot be modified orally. I understand that I have given up substantial rights by signing this agreement. I have signed this agreement freely and without any inducement or assurance of any nature. I intend this agreement to be a complete and unconditional release of all liability to the fullest extent allowed by law. I agree that if any portion of this agreement is held to be invalid, the balance, notwithstanding, shall continue in full force and effect. SIGNATURE________________________________________________________________________ PRINTED NAME____________________________________________________________________ EFFECTIVE DATE__________________________________________________________________ WITNESS SIGNATURE______________________________________________________________ PRINTED NAME OF WITNESS______________________________________________________ Parents or Guardians Additional Indemnification (Must be completed if under 18 years of age) In consideration of _____________________________________ (Minor) being permitted to use in any way the Fit for Life facilities, equipment, premises, or participate in any activity, class, program, or instruction at the Facility, I further agree to indemnify and hold harmless LCH from any claims which are brought by, or on behalf of, Minor, and which are in any way connected to such use or participation on the part of Minor. I hereby agree and consent to the Waiver and Release of Liability, Assumption of Risk, and Indemnity Agreement on behalf of Minor. PARENT OR GUARDIAN SIGNATURE_______________________________________________ PRINTED NAME OF PARENT OR GUARDIAN________________________________________ EFFECTIVE DATE__________________________________________________________________ WITNESS SIGNATURE______________________________________________________________ PRINTED NAME OF WITNESS______________________________________________________ April 2015 Page PAGE 2 of NUMPAGES 2 April 2015 Page PAGE 1 of NUMPAGES 2 Logan County Rehabilitation and Wellness Center 906 W 2nd Street, Oakley, KS 67748 785-672-8167 i j k $ ۿwj]jSjIj?]jIjI h OJ QJ ^J h