The CLIMB Registration Form Personal InformationFirst Name*Middle InitialLast Name*Date of Birth* MM slash DD slash YYYY Address* Home Address 1 Home Address 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Phone Number*Email* Caregiver/Spouse InformationFirst Name*Middle InitialLast Name*Is the address same as above?* Same address Address* Home Address 1 Home Address 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Phone Number*Email* Relationship to exercise participant*Emergency Contact Is your emergency contact the same as your Caregiver/Spouse? Same contact First Name*Last Name*Relationship*Phone Number*What are your goals for this exercise class?*How did you hear about the CLIMB?*Permission to use photograph* I grant the Indiana Parkinson Foundation, its representatives and employees the right to take photographs of me and my property with the above-identified subjects. * I authorize the Indiana Parkinson Foundation, it’s assigns and transferees to copyright, use to publish the same in print and or electronically. * I agree that the Indiana Parkinson Foundation may us such photographs of me with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising and web content. COVID-19 Release* As the participant of the CLIMB exercise program held at LivRite Fitness, I confirm that I have read, understand and agree to the WAIVER AND RELEASE OF LIABILITY and CONSENT, on my own behalf, to participation in all activities of The CLIMB exercise program. In consideration of being a participant in The CLIMB exercise program, the person executing this form acknowledges and agrees that: 1. The risk of injury or illness from infection diseases including but not limited to MRSA, influenza and COVID-19 from involvement in The CLIMB activities are significant and include the potential for death and/or permanent injury, which risks are reduced, but not eliminated by the observance of rules, and use of personal discipline. 2. I willingly agree to comply with the stated and customary terms and conditions for participation in regards to protection against infectious diseases. If, however, I observe any unusual or significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention to the nearest trainer immediately. 3. I, as the participant (and on behalf of each of my heirs, assigns, and next of kin), knowingly and freely assume all such risks, both known and unknown, and hereby release, discharge and agree to hold harmless The CLIMB and Indiana Parkinson Foundation and their respective directors, officers, employees, agents, and, if applicable, owners and/or lessors of the premises used to conduct The CLIMB’S activities (collectively the ‘releases’) from and against any liability, loss, cost or expense with regard to any injury to the fullest extent permitted by law, including disability or death, or any other loss or damage to persons or property, even if arising from the negligence of any of the releases, or others. The participant hereby assumes full responsibility for participation. Waiver of Liability-Participant* I have read the statements below and release the Indiana Parkinson Foundation and The CLIMB, its members, agents, heirs, successors and assigns, from any and all liability or cause of injury and shall indemnify and hold them harmless from any such liability whether participation was on site or by virtual classes, even if such injury or damage is the result of negligence by the Indiana Parkinson Foundation and/or The CLIMB. I have inspected the building, its environs, and the physical area where the exercise training will be conducted, and they are acceptable to me. Therefore, I release the property owner from any and all liability or cause of injury and shall indemnify and hold them harmless from any such liability. I have been diagnosed with Parkinson’s disease. I understand that a common symptom of Parkinson’s disease is loss of balance, which can lead to falls. By signing this, I represent that I am physically able to undertake the exercise program and have made full disclosure of any physical problem now existing. I agree that this exercise program will be undertaken at my own risk and that I am responsible for informing Indiana Parkinson Foundation of any exercise or activity related to the exercise program that causes discomfort and/ or pain. I also understand that is it my decision whether or not to continue the exercise program in the event of an injury or illness. By continuation of a program, I represent that I am physically able to undertake any and all physical exercise provided. Indiana Parkinson Foundation staff members are not, nor do they claim to be, physicians or possess medical knowledge. Therefore, they cannot take responsibility for any injury or illness related to this exercise class. It is recommended that you consult with your family physician prior to beginning this exercise class. If you choose to forgo the above-mentioned physical examination, we cannot be held responsible for any injury related to a pre-existing condition. Signature box*Printed Name*Date* MM slash DD slash YYYY Δ
