Liability Release Form Please read the following carefully, affirm each statement, and then Sign & Submit below: I wish to participate in the health program offered by Mosaic Health LLC. I understand there are inherent risks in participating in a program of strenuous exercise. Consequently, I have been examined by a physician of my choice and have obtained his/her approval for my participation in a fitness program within sixty (60) days of the date set forth below. No change has occurred in my physical condition since the date such approval was given which might affect my ability to participate in the health program. If a physician has not examined me, I agree to see a physician within sixty (60) days of the date set forth below to obtain his/her approval for my participation in a health program. I agree that Mosaic Health LLC shall not be liable or responsible for any injuries to me resulting from my participation in the health program and I expressly release and discharge Mosaic Health LLC from all claims, actions, judgments and the like which I may have or claim to have as a result of any injury or other damage which may occur in connection with my participation in the health program, excepting only an injury caused by the gross negligence or intentional act of such person or persons. * I have read and agree to the terms above I acknowledge that medical clearance has been attained. I understand and agree that it is my responsibility to inform Mosaic Health LLC of any conditions or changes in my health, now and on going, which might affect my ability to exercise safely and with minimal risk of injury. * I have read and agree to the terms above I understand that I am not obligated to perform nor participate in any activity that I do not wish to do, and that it is my right to refuse such participation at any time during my training sessions. I understand that should I feel lightheaded, faint, dizzy, nauseated, or experience pain or discomfort, I am to stop the activity and inform my Personal Trainer. * I have read and agree to the terms above I understand the results of any health program cannot be guaranteed and my progress depends on my effort and cooperation in and outside of the sessions. * I have read and agree to the terms above I understand that Mosaic Health LLC requires payment for each monthly program in advance of the first session of each month. Once my trainer and I have decided upon the monthly schedule and rate for service, payment must be made before the sessions are conducted. I understand that all Personal Training sessions are non-transferable and non-refundable. * I have read and agree to the terms above I understand that I have enrolled in a monthly health program and it is my responsibility to attend every scheduled session. If I fail to attend any scheduled session for the month I forfeit any opportunity to reschedule that session. * I have read and agree to the terms above I understand that the usage of any nutritional supplements is done under my own will and has not been prescribed by Mosaic Health LLC. * I have read and agree to the terms above I understand that should my Personal Trainer become ill, away on holidays or absent for any reason, all appropriate sessions will either be (1) rescheduled, or (2) credit applied on next month's invoice. * I have read and agree to the terms above I hereby give my consent to Mosaic Health LLC to use my image and likeness in its publications, advertising or other media activities (including the Internet). This consent includes, but is not limited to: (a) Permission to photograph, film, or otherwise make a video reproduction of me and/or record my voice; (b) Permission to use my name; and (c) Permission to use quotes (or excerpts of such quotes), in part or in whole, in its publications, and electronic media (including the Internet). I have read and agree to the terms above COVID-19 I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing. I further acknowledge that Mosaic Health LLC has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19. I further acknowledge that Mosaic Health LLC can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, other clients and their families. I voluntarily seek services provided by Mosaic Health LLC and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment. * I have read and agree to the terms above I attest that: (a) I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell; (b) I have not traveled internationally within the last 14 days; (c) I have not traveled to a highly impacted area within the United States of America in the last 14 days; (d) I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19; (e) I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by state or local public health authorities; (f) I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19. * I have read and agree to the terms above I hereby release and agree to hold Mosaic Health LLC harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act that may otherwise arise in any way in connection with any services received from Mosaic Health LLC. I understand that this release discharges Mosaic Health LLC from any liability or claim that I, my heirs, or any personal representatives may have with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Mosaic Health LLC. This liability waiver and release extends to all owners, partners, and employees. * I have read and agree to the terms above I understand that should either my trainer or myself knowingly become exposed to COVID-19 that all in-person sessions will be transferred to Virtual Sessions until either (a) a negative COVID-19 test result, or (b) 7 days of no symptoms. * I have read and agree to the terms above Client Name * First Name Last Name Name of Parent or Guardian Only necessary for those clients who are under the age of 18 years. First Name Last Name Date * MM DD YYYY Thank you!
