Assumption of Risk: The undersigned hereby acknowledge and agree that they understand the nature of participation in Physical Training and/or Rehabilitation (Event); that Participant is qualified, in good health, and in proper physical condition to participate therein; that there are certain inherent risks and dangers associated with the Event; and that, except as expressly set forth herein, they, knowingly and voluntarily, accept, and assume responsibility for, each of these risks and dangers, and all other risks and dangers that could arise out of, or occur during, Participant’s participation in the Event. I am voluntarily participating in training and other physical activities and using equipment while at Train Like a Pro, LLC with knowledge of the dangers and risks involved. I hereby assume and accept any and all risks associated with my participation in sports or other physical activities at Train Like a Pro, LLC (whether at Train Like a Pro, LLC’s athletic facilities or elsewhere).
Release and Waiver: The undersigned hereby RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE the Train Like a Pro, LLC and its member Institutions, or any subdivision thereof, and each of them, their officers and employees, (collectively, the “Releasees”), from and for any liability resulting from any personal injury, accident or illness (including death), and/or property loss, however caused, arising from, or in any way related to, Participant’s participation in the Event, except for those caused by the willful misconduct, gross negligence or intentional torts of the above parties, as applicable.
Indemnification and Hold Harmless: The undersigned also hereby agree to INDEMNIFY, DEFEND AND HOLD the Releasees HARMLESS from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities including, but not limited to, attorney’s fees, arising from, or in any way related to, Participant’s participation in the Event, except for those arising out of the willful misconduct, gross negligence or intentional torts of the above parties, as applicable.
Permission to Use Likeness/Name: The undersigned further agree to allow, without compensation, Participant’s likeness and/or name to appear, and to otherwise be used, in material, regardless of media form, promoting Train Like a Pro, LLC, and/or its championships, events and activities, including those of its representatives and licensees.
Severability: The undersigned expressly agree that the foregoing assumption of risk, release and waiver of liability and indemnity agreement is intended to be as broad and inclusive as is permitted by the law of the State of Florida and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
Acknowledgment of Understanding: The undersigned have read this assumption of risk, release and waiver of liability and indemnity agreement, and have had the opportunity to ask questions about the same. The undersigned fully understand this assumption of risk, release and waiver of liability and indemnity agreement, that the undersigned are giving up substantial rights in connection therewith, and that its terms are contractual, and not a mere recital. The undersigned acknowledge that they are signing this agreement freely and voluntarily.
Consent to Treatment: Consent is hereby granted by the undersigned to Train Like a Pro, LLC, including its Athletic Training Services staff, health care professionals, and consultants, to proceed with any medical or treatment, including without limitation x-ray examination, imaging studies or testing, that the professional staff considers to be necessary for the student-athlete named below. Authorization and consent is hereby granted by the undersigned to Train Like a Pro, LLC, including its Athletic Training Services staff, health care professionals, and consultants, to obtain and release health information and records for treatment, payment, and operations purposes, including for the purpose of processing insurance claims. This Consent to Treatment and Disclosure of Information is a required condition for participation in the Services offered and shall remain valid until revoked in writing.
HIPAA: Please read our HIPAA privacy notice in full below.
Financial Responsibility Statement: SELF-PAY. Time of Service Agreement - Professional services rendered to you (or your dependents) by Train Like a Pro, LLC are your sole financial responsibility. You are responsible for payment on the day of service for your treatment. In this agreement Train Like a Pro, LLC will not submit claims to any insurance company nor accept assignments of benefits.
Train Like a Pro, LLC HIPAA Notice of Privacy Practices
Effective Date: 12/26/2017
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Train Like a Pro, LLC is dedicated to maintaining the privacy of your protected health information (PHI) as part of providing professional performance coaching. In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time.
We use and disclose health information about you for treatment, payment, and healthcare operations. For example:
Treatment: We may use and disclose your PHI to provide, coordinate, or manage your health care and any related services.
Payment: Your PHI will be used, as needed, to obtain payment for your health care services.
Healthcare Operations: We may use or disclose, as needed, your PHI in order to support the business activities of Train Like a Pro, LLC.
Other Uses and Disclosures: As permitted by federal and state law, we may use or disclose your PHI without your consent or authorization for several other reasons. Subject to certain requirements, we may give out PHI without prior authorization for public health purposes, abuse or neglect reporting, health oversight, research studies, funeral arrangements and organ donation, workers’ compensation purposes, and emergencies. We also disclose PHI when required by law, such as in response to a request from law enforcement in specific circumstances.
You have the following rights regarding PHI we maintain about you:
If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, contact info@mattwilkins.me. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
For further information about Train Like a Pro’s privacy policies, please contact info@mattwilkins.me.