Central North Alabama Health Services, Inc.’s (CNASHI) participation in a Get Moving Classes to provide education about High Blood pressure and exercising and to provide a workout session for participants (Zumba/General Exercise)

I acknowledge and understand that my participation in a Class could result in my exposure to bodily injury, illness, loss or death, as well as property losses and/or damage to property. I HEREBY AGREE AS FOLLOWS:

1. In consideration of being allowed to participate in the Get Moving Classes and use of Central North Alabama Health Services Inc. (CNAHSI) facilities, I do forever waive, release and discharge all instructors and CNAHSI, and all others acting on their behalf from any and all claims or liabilities for injuries or damages to my person and/or property, including those caused by negligent acts or omission of any of those mentioned or others acting on their behalf arising out of or connected with my participation in this activity, and I hereby agree to submit any and all claims to binding arbitration and abide by the judgment of that arbitration.

2. I fully understand that I may injure myself as a result of my participation in this activity and forever waive release and discharge all instructors and CNAHSI, from any liability now or in the future, including but not limited to muscle or ligament tears, strains, sprains, pulls , broken bones, dislocations, joint problems, shin splints, heat exhaustion, knee, back, hip or foot injuries, as well as the potential for heart attack, paralysis or death, however caused, occurring during or after my participation in this exercise class.

3. I declare myself to be physically sound and suffering from no condition, impairment, disease, infirmity or other illness that would prevent my participation in this activity. I understand that a medical examination to assure my physical fitness is desirable and obtaining such examination is my own responsibility. I acknowledge that I have had a physical examination and have been given my physician’s permission to participate in this activity or I have decided to participate in this activity without the approval of my physician and do assume all responsibility for my participation in this activity. I fully understand that I am forever giving up, in advance, any right to sue or make claim against the parties I am releasing, if I suffer any injuries or damages, even though I do not know what or how extensive those injuries or damages might be. I am voluntarily assuming the risk of those injuries or damages.

4. In signing this release, I acknowledge and represent that I read the foregoing Waiver of Liability Form, understand it and sign it voluntarily as my own free act and deed and am not under any physical or emotional duress to sign. I am at least eighteen (18) years of age and fully competent. In case of emergency, I agree to allow the above parties to call for emergency medical assistance and I am aware that I am financially responsible to those medical services.

5. I understand that the health care provider that is offering health education during the Get Moving Classes is not my personal health care provider and is offering the recommendations and self-care solely for my educational purposes. I understand that this means that I do not have a health care provider/patient relationship for purposes of this event.

6. I understand that my participation in exercising during Get Moving Classes is entirely voluntary and I can refuse to participate or withdraw consent prior to screening without any consequences.


You acknowledge and agree that by clicking on a “Submit" button and registering for a Get Moving Class, you are submitting a legally binding electronic signature and are entering into a legally binding contract. You acknowledge that your electronic submission constitutes your agreement and intent to be bound by these terms. Pursuant to any applicable statutes, regulations, rules, ordinances or other laws, including without limitation the United States Electronic Signatures in Global and National Commerce Act, P.L. 106-229 (the "E-Sign Act") or other similar statutes, YOU HEREBY AGREE TO THE USE OF ELECTRONIC SIGNATURES, CONTRACTS, ORDERS AND OTHER RECORDS AND TO ELECTRONIC DELIVERY OF NOTICES, POLICIES AND RECORDS OF TRANSACTIONS INITIATED OR COMPLETED THROUGH THE Central North Alabama Health Services, Inc. (CNAHSI) WEBSITE OR SERVICES OFFERED BY CNAHSI. Further, you hereby waive any rights or requirements under any statutes, regulations, rules, ordinances, or other laws in any jurisdiction which require an original signature or delivery or retention of non-electronic records, or to payments or the granting of credits by other than electronic means.

Central North Alabama Health Services, Inc.’s (CNASHI) participation in a Get Moving Classes to provide education about High Blood pressure and exercising and to provide a workout session for participants (Zumba/General Exercise)

I acknowledge and understand that my participation in a Class could result in my exposure to bodily injury, illness, loss or death, as well as property losses and/or damage to property. I HEREBY AGREE AS FOLLOWS:

1. In consideration of being allowed to participate in the Get Moving Classes and use of Central North Alabama Health Services Inc. (CNAHSI) facilities, I do forever waive, release and discharge all instructors and CNAHSI, and all others acting on their behalf from any and all claims or liabilities for injuries or damages to my person and/or property, including those caused by negligent acts or omission of any of those mentioned or others acting on their behalf arising out of or connected with my participation in this activity, and I hereby agree to submit any and all claims to binding arbitration and abide by the judgment of that arbitration.

2. I fully understand that I may injure myself as a result of my participation in this activity and forever waive release and discharge all instructors and CNAHSI, from any liability now or in the future, including but not limited to muscle or ligament tears, strains, sprains, pulls , broken bones, dislocations, joint problems, shin splints, heat exhaustion, knee, back, hip or foot injuries, as well as the potential for heart attack, paralysis or death, however caused, occurring during or after my participation in this exercise class.

3. I declare myself to be physically sound and suffering from no condition, impairment, disease, infirmity or other illness that would prevent my participation in this activity. I understand that a medical examination to assure my physical fitness is desirable and obtaining such examination is my own responsibility. I acknowledge that I have had a physical examination and have been given my physician’s permission to participate in this activity or I have decided to participate in this activity without the approval of my physician and do assume all responsibility for my participation in this activity. I fully understand that I am forever giving up, in advance, any right to sue or make claim against the parties I am releasing, if I suffer any injuries or damages, even though I do not know what or how extensive those injuries or damages might be. I am voluntarily assuming the risk of those injuries or damages.

4. In signing this release, I acknowledge and represent that I read the foregoing Waiver of Liability Form, understand it and sign it voluntarily as my own free act and deed and am not under any physical or emotional duress to sign. I am at least eighteen (18) years of age and fully competent. In case of emergency, I agree to allow the above parties to call for emergency medical assistance and I am aware that I am financially responsible to those medical services.

5. I understand that the health care provider that is offering health education during the Get Moving Classes is not my personal health care provider and is offering the recommendations and self-care solely for my educational purposes. I understand that this means that I do not have a health care provider/patient relationship for purposes of this event.

6. I understand that my participation in exercising during Get Moving Classes is entirely voluntary and I can refuse to participate or withdraw consent prior to screening without any consequences.

You acknowledge and agree that by clicking on the checkbox above and by clicking on a "submit" button , you are submitting a legally binding electronic signature and are entering into a legally binding contract. You acknowledge that your electronic submission constitutes your agreement and intent to be bound by these terms. Pursuant to any applicable statutes, regulations, rules, ordinances or other laws, including without limitation the United States Electronic Signatures in Global and National Commerce Act, P.L. 106-229 (the "E-Sign Act") or other similar statutes, YOU HEREBY AGREE TO THE USE OF ELECTRONIC SIGNATURES, CONTRACTS, ORDERS AND OTHER RECORDS AND TO ELECTRONIC DELIVERY OF NOTICES, POLICIES AND RECORDS OF TRANSACTIONS INITIATED OR COMPLETED THROUGH THE Central North Alabama Health Services, Inc. (CNAHSI) WEBSITE OR SERVICES OFFERED BY CNAHSI. Further, you hereby waive any rights or requirements under any statutes, regulations, rules, ordinances, or other laws in any jurisdiction which require an original signature or delivery or retention of non-electronic records, or to payments or the granting of credits by other than electronic means.

In consideration of my patient status with Central North Alabama Health Services, Inc., ("Company"), I hereby give my consent to photographing of myself and/or the recording of my voice. The Company is hereby authorized to use or cause to be used said still photographs or video footage, recordings of my voice and my name for advertising, publicity, commercial or other business purposes.

The company has my authorization to reproduce or cause to be reproduced and used such photographs and/ or recordings. The same may be exhibited in all domestic and foreign markets. I understand that others may use and/or reproduce said photographs and/or recordings with or without the Company's consent.

I hereby release the Company, any of it's associated or affiliated companies, their directors, officers, agents, employees, customers and the Company's appointed advertising agencies, officers, directors, agents and employees from all claims of any kind on account of such use.

You acknowledge and agree that by clicking on the checkbox above and by clicking on a "submit" button and signing up for a Get Moving Class, you are submitting a legally binding electronic signature and are entering into a legally binding contract. You acknowledge that your electronic submission constitutes your agreement and intent to be bound by these terms. Pursuant to any applicable statutes, regulations, rules, ordinances or other laws, including without limitation the United States Electronic Signatures in Global and National Commerce Act, P.L. 106-229 (the "E-Sign Act") or other similar statutes, YOU HEREBY AGREE TO THE USE OF ELECTRONIC SIGNATURES, CONTRACTS, ORDERS AND OTHER RECORDS AND TO ELECTRONIC DELIVERY OF NOTICES, POLICIES AND RECORDS OF TRANSACTIONS INITIATED OR COMPLETED THROUGH THE Central North Alabama Health Services, Inc. (CNAHSI) WEBSITE OR SERVICES OFFERED BY CNAHSI. Further, you hereby waive any rights or requirements under any statutes, regulations, rules, ordinances, or other laws in any jurisdiction which require an original signature or delivery or retention of non-electronic records, or to payments or the granting of credits by other than electronic means.

In consideration of my patient status with Central North Alabama Health Services, Inc., ("Company"), I hereby give my consent to photographing of myself and/or the recording of my voice. The Company is hereby authorized to use or cause to be used said still photographs or video footage, recordings of my voice and my name for advertising, publicity, commercial or other business purposes.

The company has my authorization to reproduce or cause to be reproduced and used such photographs and/ or recordings. The same may be exhibited in all domestic and foreign markets. I understand that others may use and/or reproduce said photographs and/or recordings with or without the Company's consent.

I hereby release the Company, any of it's associated or affiliated companies, their directors, officers, agents, employees, customers and the Company's appointed advertising agencies, officers, directors, agents and employees from all claims of any kind on account of such use.

You acknowledge and agree that by clicking on the checkbox above and by clicking on a "submit" button and signing up for a Get Moving Class, you are submitting a legally binding electronic signature and are entering into a legally binding contract. You acknowledge that your electronic submission constitutes your agreement and intent to be bound by these terms. Pursuant to any applicable statutes, regulations, rules, ordinances or other laws, including without limitation the United States Electronic Signatures in Global and National Commerce Act, P.L. 106-229 (the "E-Sign Act") or other similar statutes, YOU HEREBY AGREE TO THE USE OF ELECTRONIC SIGNATURES, CONTRACTS, ORDERS AND OTHER RECORDS AND TO ELECTRONIC DELIVERY OF NOTICES, POLICIES AND RECORDS OF TRANSACTIONS INITIATED OR COMPLETED THROUGH THE Central North Alabama Health Services, Inc. (CNAHSI) WEBSITE OR SERVICES OFFERED BY CNAHSI. Further, you hereby waive any rights or requirements under any statutes, regulations, rules, ordinances, or other laws in any jurisdiction which require an original signature or delivery or retention of non-electronic records, or to payments or the granting of credits by other than electronic means.