Fit Club Phase 2 Registration Form

Thank you for your interest in Fit Club Phase 2. Please complete this survey to register if you have previously completed MUSC Wellness Centers Breast Cancer Survivors' Fit Club.

For any questions, please contact Cindi Day dayc@musc.edu

Have you completed MUSC Wellness Centers Breast Cancer Survivors' Fit Club?

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Yes

NOTICE!!! You must complete MUSC Wellness Centers Breast Cancer Survivors' Fit Club in order to participate in Fight Back. Click here if you are interested in participating in the next session of Breast Cancer Survivors' Fit Club.

Approximate date you completed Breast Cancer Survivors Fit Club:

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First Name:

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Last Name:

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Date of Birth:

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Y-M-D

Gender:

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Male

Female

Other

Address:

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State:

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Zip Code:

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Mobile Phone:

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Email:

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Emergency Contact Name:

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Emergency Contact Phone Number:

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Release of Liability and Waiver Agreement

In consideration of my obtaining guest privileges and being allowed to use the facilities and equipment of the MUSC Wellness Center (MUSC), I hereby release, waive, discharge and agree not to sue MUSC and its affiliates, its trustees, officers, agents or employees (hereinafter referred to as "Releasees") from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or relating to any loss, damage or injury, including but not limited to those posed by COVID-19, including death, that may be sustained by me, arising in connection with my return or participation in activity at the MUSC Wellness Center, or while in or upon the premises. I voluntarily assume full responsibility for any risks of loss, property damage or personal injury, including death that may be sustained by me, or any loss or damage to property owned by me, as a result of my return/participation. I further hereby agree to indemnify and save and hold harmless MUSC, from any loss, liability, damage or costs that may incur as a result of my participation. It is my express intent that this Release shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representative, if I am deceased.

I understand that strength, flexibility, sports and aerobic exercise, including the use of equipment involves risk of injury. I am voluntarily participating in these activities and using the equipment with knowledge of the dangers involved. I assume the risk of injury that might happen to me using the facilities and participating in the programs of (MUSC).

I represent to (MUSC) that I am physically fit to participate in the activities and programs of the Center and that I will not extend myself beyond my abilities, or if I do so, it will be at my own risk.

I have been informed that I should consult with a physician concerning my participating in physical activity and obtain for a physician, advice as to how I should participate in relationship to my state of physical condition. I have also been informed that I should periodically update my state of physical condition with a physician. I either have obtained such advice from a physician or acknowledge that I have decided to participate in physical activities without obtaining the advice of a physician.

All policies must be followed by members and guests at all times. Any behavior deemed by Management to be adverse to the enjoyment of the facility by others may result in termination of contract.

I understand that the Waiver and Release of Liability above stated is in broad terms. If any portion of this Waiver and Release of Liability is held invalid, the remainder will continue in effect.

I certify that I am age 18 or older. I acknowledge that I have carefully read this document in its entirety and have had the opportunity to ask questions concerning this document before signing, that I understand and agree to comply with its terms and conditions, and that I have signed it knowingly and voluntarily.

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