RELEASE FORM FOR FITNESS AND EXERCISE HEALTHY KIDS

RELEASE FORM FOR FITNESS AND EXERCISE
HEALTHY KIDS WEIGHT AND WELLNESS PROGRAM
THE Florida Hospital Healthy kid’s Weight Management Program offers individual physical
fitness programs (“Activities”). The Activities will take place at Florida Hospital, the Center for
Child and Family Wellness, or other location designated by Florida Hospital. Individuals
enrolled in the Program are eligible to participate in Activities sponsored by the program upon
the completion of this Registration and Release (“Form”)
RELEASE
In consideration of being permitted to participate in the Healthy Kid’s program, I hereby agree to
release Florida Hospital, the Center for Child and Family Wellness, their respective agents,
officers, directors, and employees, of an form any and all liability, claims, demands or causes of
action whatsoever arising out of our related to any loss, damage, or injury, including death, that
may be sustained by me, or any property of mine, while participating in, waiting to participate in,
or en route to participate in Program Activities.
I further agree to indemnify and hold harmless Florida Hospital, the Center for Child and Family
Wellness and their respective officers, employees, directors and agents against all claims, suits,
losses, damages and costs, including but not limited to court costs and reasonable attorney’s
fees on account of any injury (including my death) to myself or my property arising out of my
participation in Program Activities.
Being aware that participation in sports or physical activities can be physically demanding and
can result in accident or injuries (i.e. those risks inherent in any sport/exercise activity
regardless of the medical condition of the participant) including, in rare instances, death, the
Program has advised me that I should consult with my own physician and obtain his or her
opinion as to the advisability of my participating in Program Activities.
I realize that I will be instructed by program personnel, during the Activities, I hereby recognize I
must adhere to these instructions, or I will forfeit my privileges to participate in the Program.
I hereby represent to the Healthy Kid’s Weight & Wellness Program that I am in good health and
suffer from no physical impairment (other than the problems stated on my participant
information sheet) that would limit my ability to participate in Program Activities. I acknowledge
that neither the Program nor its coaches, instructors, employees or agents have rendered any
medical advice to me or given any opinion or diagnosis of my current medical condition nor are
they authorized to do so. If my physical condition should every change or if I should experience
difficulty when participating in any Program Activity, I agree to discontinue my participation until I
consult with my personal physician.
Name of child (Please
Print):____________________________________________________________
Name of Parent/legal guardian (Please
Print):_______________________________________________
Signature of Parent/legal
guardian:_______________________________________________________
Name of participating siblings (Please
Print):_________________________DOB___________________
_________________________DOB___________________
______ __________________
DOB___________________
Name of additional participant parent/legal
guardian:__________________DOB___________________
Rev:1 /2013_