Release of Liability Form and Emergency Contact Information
Emergency Contact Information and Release of Liability Form
Name and contact information of two people who we can contact in case of emergency:
Name, Phone Number(s):
Contact 1:
Contact 2:
In the event of the participant absence or withdrawal from the Program, for any reason whatsoever, participant will remain fully responsible for fees associated with the Program and all applicable lodging and travel expenses. Under no circumstance will Empowered For Life, Inc., or Mary Shackelford Wellness Solutions (hereafter called Organizers) refund any payments made by the participant for non-completion of the retreat program. By signing this Agreement, the participant agrees to be legally obligated to pay the full amount of this Program.
The Participant understands that the Organizers are not acting in the capacity of a doctor, licensed dietician-nutritionist, psychologist or other licensed or registered professional (including registered nurse). Accordingly, the participants understands that the Organizers are not providing health care, medical, psychological or nutrition therapy services and will not diagnose, treat or cure in any manner whatsoever any disease, condition or other physical or mental ailment of the human body. Participants are encouraged to continue to visit and to be treated by his/her healthcare professionals, including, without limitation, a physician. All information received is educational only and is certainly not meant to take the place of your seeing licensed health professionals.
The Participant acknowledges that the Participant takes full responsibility for the Participant’s life and well-being and all decisions made during and after this program.
The Participant expressly assumes the risks of the Program, whether or not such risks were created or exacerbated by Organizers. The Participant releases Organizers, their heirs, executors, administrators and assigns, its officers, directors, shareholders, employees, teachers, lecturers, agents, health coaches and staff (collectively, the Releasees) from any and all liability, damages, causes of action, allegations, suits, sums of money, claims and demands whatsoever, in law, admiralty or equity, which against the Releasees, the Participant ever had, now has or will have in the future against the Releasees, arising from the Participant’s past or future participation in, or otherwise with respect to, the Program, unless arising from the gross negligence of the Releasees.
Participant is liable for any damage to the premises, outside of reasonable and ordinary wear and tear, and shall be responsible to clean repair and/or replace in a timely manner not to exceed 10 days form the date of completion of the program.
The Organizers, will not be liable for any damage to the property of participants located on the premises nor for the loss or damage of any property of the participants by theft, casualty, or otherwise, unless directly caused by the negligence of the Organizers.
Participants hereby agree to indemnify, defend and hold Organizers, hereinafter referred to an “Indemnitee”, harmless from any suits, claims, losses, damages or expenses, including reasonable attorney fees and expenses, which any Indemnitee may suffer, sustain or incur as a result of or in connection with the operation or use of SMC facilities by participants , except as such suits, claims, losses, damage or expenses arise from the gross negligent act or omissions of Indemnitee.
Participant Name (Printed):
Participant Name (Signature):
Date:
Please scan and email signed form to susan@empoweredforlife.net or mail to Susan Osborn, 720 Quince Circle, Boulder, CO 80304.
Thank You.
Name and contact information of two people who we can contact in case of emergency:
Name, Phone Number(s):
Contact 1:
Contact 2:
In the event of the participant absence or withdrawal from the Program, for any reason whatsoever, participant will remain fully responsible for fees associated with the Program and all applicable lodging and travel expenses. Under no circumstance will Empowered For Life, Inc., or Mary Shackelford Wellness Solutions (hereafter called Organizers) refund any payments made by the participant for non-completion of the retreat program. By signing this Agreement, the participant agrees to be legally obligated to pay the full amount of this Program.
The Participant understands that the Organizers are not acting in the capacity of a doctor, licensed dietician-nutritionist, psychologist or other licensed or registered professional (including registered nurse). Accordingly, the participants understands that the Organizers are not providing health care, medical, psychological or nutrition therapy services and will not diagnose, treat or cure in any manner whatsoever any disease, condition or other physical or mental ailment of the human body. Participants are encouraged to continue to visit and to be treated by his/her healthcare professionals, including, without limitation, a physician. All information received is educational only and is certainly not meant to take the place of your seeing licensed health professionals.
The Participant acknowledges that the Participant takes full responsibility for the Participant’s life and well-being and all decisions made during and after this program.
The Participant expressly assumes the risks of the Program, whether or not such risks were created or exacerbated by Organizers. The Participant releases Organizers, their heirs, executors, administrators and assigns, its officers, directors, shareholders, employees, teachers, lecturers, agents, health coaches and staff (collectively, the Releasees) from any and all liability, damages, causes of action, allegations, suits, sums of money, claims and demands whatsoever, in law, admiralty or equity, which against the Releasees, the Participant ever had, now has or will have in the future against the Releasees, arising from the Participant’s past or future participation in, or otherwise with respect to, the Program, unless arising from the gross negligence of the Releasees.
Participant is liable for any damage to the premises, outside of reasonable and ordinary wear and tear, and shall be responsible to clean repair and/or replace in a timely manner not to exceed 10 days form the date of completion of the program.
The Organizers, will not be liable for any damage to the property of participants located on the premises nor for the loss or damage of any property of the participants by theft, casualty, or otherwise, unless directly caused by the negligence of the Organizers.
Participants hereby agree to indemnify, defend and hold Organizers, hereinafter referred to an “Indemnitee”, harmless from any suits, claims, losses, damages or expenses, including reasonable attorney fees and expenses, which any Indemnitee may suffer, sustain or incur as a result of or in connection with the operation or use of SMC facilities by participants , except as such suits, claims, losses, damage or expenses arise from the gross negligent act or omissions of Indemnitee.
Participant Name (Printed):
Participant Name (Signature):
Date:
Please scan and email signed form to susan@empoweredforlife.net or mail to Susan Osborn, 720 Quince Circle, Boulder, CO 80304.
Thank You.
