Minor's Name
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First Name
Last Name
Birthdate
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MM
DD
YYYY
Phone
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(###)
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####
Email
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Emergency Contact Name
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First Name
Last Name
Relationship
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Phone
*
(###)
###
####
Have you ever had a heart attack within the previous 6 months?
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Do you have a pacemaker?
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Have you had a heart bypass or valvular disease within the previous 6 months?
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Do you have congestive heart failure?
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Do you have chronic obstructive pulmonary disease (COPD)?
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Do you have an intrathecal pain pump or any electro stimulation implant device? (i.e spinal stimulator implant)
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Do you have any chronic or acute kidney conditions?
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Do you currently have a fever, infection or injury?
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Are you currently taking blood pressure medication?
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Are you pregnant?
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Do you have a history of seizure disorders?
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Do you have cold allergies with known skin reactions to cold?
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Do you have any blood disorders (such as hemophilia or blood clots)?
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Do you have any major circulatory dysfunction (such as deep vein thrombosis)?
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Do you have Heart Arrhythmia or Atrial Fibrillation?
*
Do you have any open wounds, sores, or healing disorders?
*
Are you under the influence of drugs or alcohol?
*
*PLEASE READ CAREFULLY BEFORE SIGNING*
Physical Capability Requirements
Participation in a Whole Body Cryotherapy (WBC) session involves exposure to extreme cold temperature for a short period of time (not to exceed three and one-half (3:30) minutes per session). During the WBC session, the chamber technician will be present during the entire duration of your session. Additionally, you are free to walk out of the chamber at any time. The cold therapy session is followed by a five (5) to ten (10) minute period of light to moderate exercise.
LIABILITY AND MEDICAL RELEASE AND INDEMNIFICATION AGREEMENT
In consideration of being permitted by Touch N Go Soccer Academy, LLC to participate in their services, I hereby waive any and all claims and damages for personal injury
or death which may occur as a result of my participation. I understand and agree that:
1. This release is intended to discharge in advance Touch N Go Soccer Academy, LLC, its officers, officials, employees, agents, and volunteers from and against all liability arising out of or connected in any way with my participation in these activities;
2. Participation may involve risk of serious injury, illness, disability, or death and may result not only as a result of my actions, negligence, or inaction, but also from the action, negligence, or inaction of others, including their owners, officers officials employees, or volunteers and may result from
the conditions of the facilities, equipment, or areas where such activities are being conducted;
3. Knowing the risks involved and the contraindications related, I nevertheless chose voluntarily to request permission to participate;
4. I will indemnify and hold harmless Touch N Go Soccer Academy, LLC, its owners, officers, officials, employees, and volunteers from any loss, liability, damage, cost, or expense, including litigation of any form, arising out of or connected in any manner with my participation in such activities;
5. I am in good health and have no physical condition expressed in the ‘Contraindications’ or otherwise which would preclude me from safely participating in such activities;
6. I understand and agree that this release is intended to be as broad and inclusive as permitted under the law of the State in which it is executed and that if any portion of this Hold Harmless, Release and Indemnification Agreement should be determined to be invalid, it is my intent that the remaining provisions shall continue in full force and effect.
I HAVE CAREFULLY READ THIS RELEASE INDEMNIFICATION AND HOLD HARMLESS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A POTENTIAL CONFLICT BETWEEN MYSELF, AND MY HEIRS AND TG CRYO I VOLUNTARILY AGREE TO EACH OF THE TERMS AND
PROVISIONS HEREIN AND SIGN THIS OF MY OWN FREE WILL.
I understand that it is mandatory to wear a headband, mask, mittens, tube socks, and enclosed footwear during my Whole Body Cryotherapy (WBC) session as a safety precaution. I also understand that I should not remove Personal Protective Equipment (PPE) at anytime during my Whole Body Cryotherapy (WBC) session.
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I understand that wet or damp clothing cannot be worn at anytime during a Whole Body Cryotherapy (WBC) session. Please ask the receptionist for more information.
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I have completely read this waiver.
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I authorize Touch N Go Soccer Academy, LLC to take pictures and video for use on our website, social media, or promotional material.
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Parent or Guardian Signature (Please type name)
Today's Date
MM
DD
YYYY
Customer is able to use the Whole Body Cryotherapy (WBC) chamber based on a review of contraindications:
Additional Physician Comments
Physician Name
First Name
Last Name
