I agree as follows: I fully understand and acknowledge that (a) the activities in which I will engage as part of the injury screening provided by Samson Strength & Performance PT, LLC and the physical therapy activities and equipment I may use as a part of that treatment have inherent risks, dangers, and hazards and such exists in my use of any equipment and my participation in these activities; (b) my participation in such activities and/or use of such equipment may result in injury or illness including, but not limited to bodily injury, disease, strains, fractures, partial and/or total paralysis, death or other ailments that, could cause serious disability; (c) these risks and dangers may be caused by the negligence of the representatives or employees of Samson Strength & Performance PT, LLC, the negligence of the participants, the negligence of others, accidents, or other causes. By my participation in these activities and for use of equipment, I hereby assume all risks and dangers and all responsibility for any losses and/or damages whether caused in whole or in part by the negligence or the conduct of the representatives or employees of Samson Strength & Performance PT, LLC, or by any other person. I, on behalf of myself, my personal representatives, and my heirs, hereby voluntarily agree to release, waive, discharge, hold harmless, defend, and indemnify Samson Strength & Performance PT, LLC and their representatives, and employees from any and all claims, actions or losses for bodily injury, property damage, wrongful death, loss of services or otherwise which may arise out of my use of any equipment or participation in these activities. I specifically understand that I am releasing, discharging, and waiving any claims or actions that I may have presently or in the future for the negligent acts or other conduct by the representatives or employees of Samson Strength & Performance PT, LLC.
I HAVE READ THE ABOVE CONSENT AND RELEASE AND BY SIGNING IT AGREE IT IS MY INTENTION TO EXEMPT AND RELIEVE SAMSON STRENGTH & PERFORMANCE PT, LLC FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH CAUSED BY NEGLIGENCE OR ANY OTHER CAUSE.
I authorize Samson Strength & Performance PT, LLC and its associated health professionals to collect and publish photos and/or videos of my injury screen. These photos/videos can be used for promotional and informational marketing material.
I authorize Samson Strength & Performance PT, LLC to use the information provided on this form to keep in touch with me and provide updates and marketing to the email and phone number provided.