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Next of Kin Name & Phone Number

Other injuries or illness....

Release of Indemnity, Waiver if Claims, Assumption of Risk, Indemnity Agreement and Jurisdiction Agreement BY SIGNING THIS DOCUMENT YOU WAIVE CERTAIN LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE WARNING: This is a legal document that affects your rights. This is an agreement for participating in training with MIND BODY REPUBLIC. The ‘Trainer’ refers to the Australian Registered Business ‘MIND BODY REPUBLIC’. The ‘Activity’ refers to the participation in strength, fitness and conditioning training and general advices. • I acknowledge that it is a condition of participating in this Activity that I do so at my own risk. • I accept all risks and hereby indemnify and release the Trainer, their agents, affiliates, employees, sponsors, promoters and any person or body directly or indirectly associated with the Trainer, against all liability (including liability for their negligence and the negligence of others) claims, demands and proceedings arising out of or connected with my participation in this activity. • If I bring children with me I accept all risks and indemnify and release the trainer, their agents, affiliates, employees, sponsors, promoters and any person or body directly and indirectly associated with the Trainer, against all liability (including liability for their negligence and the negligence of others) claims, demands and proceedings arising out of or connected with the children being present and agree to keep them in the designated areas. • This release and indemnity continues forever and binds my heirs, successors, executors, personal representatives and assigns. • I acknowledge that participating in this activity may involve a risk of serious injury or even death from various causes including; exhaustion, dehydration, equipment failure and accidents with equipment and surroundings. • I recognise the difficulties associated with the activity and attest I am physically fit to participate safely in this activity and that a qualified medical practitioner has not advised me otherwise. • I understand the demanding physical nature of this activity. In the event that I become aware of any medical condition, injury or impairment that may be detrimental to my health if I participate in this activity my trainer will be immediately informed. By continuing to participate in this activity, I accept the risks despite these conditions and am still, and always will be under the terms of this agreement. • I give consent for the Trainer to use imagery and media for the promotion of their business and website. • I certify that I am 18 years old and have read this document and fully understand it OR As a parent or guardian of the participant (a) I agree to the above for myself and on behalf of the participant and (b) I indemnify and will keep indemnified any person or body directly or indirectly associated with the conduct of the activity on the term referred to above. And, I do hereby acknowledge and agree; a) that the athletic activities I am participating in requires a moderate to high degree of effort and are designed to be high intensity, and are intended to maximally challenge my cardiovascular endurance, stamina, strength, flexibility, speed, power, coordination, agility, balance and accuracy; b) that I honestly represent my level of fitness, health, nutrition, use of medication, medical history and current physical, mental and medical condition to MIND BODY REPUBLIC; c) That although MIND BODY REPUBLIC take steps to reduce the risks and increase the safety of all athletic activities, it is not possible for MIND BODY REPUBLIC to make these athletic activities completely safe; d) That I am personally responsible for my preparation prior to athletic activities, my concentration and attention during these athletic activities, and for my post activity rest and recovery; e) That I will learn and obey the rules and regulations of MIND BODY REPUBLIC and that I will follow the instructions and directions of MIND BODY REPUBLIC during athletic activities; f) That I will inform MIND BODY REPUBLIC immediately should I feel any pain, discomfort, fatigue or nausea or other symptoms I may suffer during and immediately after athletic activities; g) That I may stop participating at any time and that I may be directed by MIND BODY REPUBLIC should I display any noticeable signs of distress; h) That I consent to receive First Aid and medical treatment by MIND BODY REPUBLIC in the event of an accident, injury or illness during athletic activity; i) That MIND BODY REPUBLIC may videotape, audiotape or photograph you for instructional and promotional purposes without payment of any kind to you and without further notice to you or permission from you. Release of Liability, Waiver of Claims, Assumption of Risk, Indemnity Agreement and jurisdiction agreement RELEASE OF LIABILITY, WAIVER OF CLAIMS AND INDEMNITY AGREEMENT In consideration of MIND BODY REPUBLIC, allowing me to participate in MIND BODY REPUBLIC athletic activities, and for other good and valuable consideration, the receipt and sufficiency of which is acknowledged, I hereby agree as follows: 1. TO WAIVE ANY AND ALL CLAIMS that I have or may have in the future against MIND BODY REPUBLIC and their owners, volunteers, directors, officers, employees, trainers, instructors, agents, officials, independent contractors, servants, representatives, successors and assigns (all of whom are hereinafter referred to as “RELEASEES”)and TO RELEASE THE RELEASES from any and all liability for any loss, damage, expense or injury including death that I may suffer or that my next of kin may suffer as a result of my participation in climbing and transportation activity, DUE TO ANY CAUSE WHATSOEVER, INCLUDING NEGLIGENCE, BREACH OF CONTRACT, OR BREACH OF ANY STATUTORY OR OTHER DUTY OF CARE, ON THE PART OF THE RELEASEES AND INCLUDING THE FAILURE ON THE PART OF THE RELEASEES TO SAFEGUARD OR PROTECT ME FROM THE RISKS, DANGERS ABD HAZARDS OF ATHLETIC ACTIVITIES; 2. TO HOLD HARMLESS AND INDEMNIFY THE RELEASEES from any and all liability for any property damage or personal injury to any third party resulting in my participation in athletic activities 3. TO HOLD HARMLESS AND INDEMNIFY THE RELEASEES from any and all liability for any costs they may incur for medical costs, emergency transportation and litigation resulting from my participation athletic activities; 4. That this agreement shall be effective and binding upon my heirs, next of kin, executors, administrators, assigns and representatives, in the event of my death or incapacity; 5. This agreement and any rights, duties, obligations as between the parties to this agreement shall be governed by and interpreted solely in accordance with the laws of Australia and no other jurisdiction; and 6. Any litigation involving the parties to this agreement shall be brought solely with NSW and shall be within the exclusive jurisdiction of the Courts of NSW Payment of Fees Our fee policy required that all memberships be paid in advance. The method of payment for fees in through CASH or DIRECT DEPOSIT I CONFIRM THAT I AM THE FULL AGE OF EIGHTEEN (18) YEARS OR AM THE LEGAL GUARDIAN/PARENT OF AN UNDER 18 YEAR OLD PARTICIPANT AND I HAVE READ AND UNDERSTOOD THIS AGREEMENT PRIOR TO SIGNING IT, AND I AM WAIVING CERTAIN LEGAL RIGHTS WHICH I OR MY HEIRS, NEXT OF KIN, EXECUTORS, ADMINISTRATORS, ASSIGNS AND REPRESENTATIVES MAY HAVE AGAINST MIND BODY REPUBLIC. I certify that the above information is true and correct. I have read and understood the TERMS AND CONDITIONS OF TRADE (attached) of AMY HANGER and MIND BODY REPUBLIC which form part of, and are intended to be read in conjunction with this screening form and liability waiver and agree to be bound by those conditions. I authorise the use of my personal information as detailed in the Privacy Act clause therein.

Waiver

Waiver Form