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FREE Health Check Registration 2019

Registration includes Free Lunch!

Name *
Name
Phone
Phone
Home Address
Home Address
Birthday
Birthday
If you wish to pre-register for a blood draw, please select one of the available time slots. (ex 9-10am etc or no blood draw)
Have you attended the WellBatavia Festival in the past?
Please read carefully:
Check this box if you
Waiver and Release/ Photographic Release
WAIVER AND RELEASE. I understand that my consent to this Waiver and Release Agreement (“Agreement”) is given in consideration for being allowed to participate in the WellBatavia Prevention Village Health Screening in June 2019 and its affiliated activities and events (“Event”). I hereby covenant that I am in good physical condition and am solely responsible for my personal health, safety and personal property. I understand that the Event is a potentially hazardous activity and I hereby assume, voluntarily, full and complete responsibility for any injury, accident, or loss that may occur during my participation in the Event or while on Event Premises. I, for myself, my heirs and next of kin, administrators and executors, hereby unconditionally and irrevocably release and hold harmless, and covenant not to file suit against, the WellBatavia Initiative and Committee, Catalyst Physiotherapy, Performance and Wellness, LLC, City of Batavia, Batavia Mainstreet, Batavia Park District, Kane County, any and all event sponsors, organizers, volunteers and their respective parents, subsidiaries, successors, assigns, affiliates, suppliers, licensees, and the respective directors, officers, board members, employees, shareholders, councilpersons, contractors and agents of same (collectively, “Released Parties”) for any and all injuries, damages, claims or losses, now existing or hereafter arising, known or unknown, which I, my minor children attending the Event, and/or representatives may sustain while participating, in any way, in the Event or while on Event Premises, regardless of the form or action or basis of the claim, whether in contract or tort, including claims arising from or relating to performance of medical services or disbursement of over-the-counter medication by any of the Released Parties at the Event, strict liability and sole negligence of the Released Parties. I understand that I am responsible for any and all medical coverage for myself, my minor children, and/or representatives throughout the duration of the Event. I further hereby assume, voluntarily, full and complete responsibility for any injury, accident, or loss that may occur as a result of my voluntary participation in any and all health screening and associated tests at the Event. I further acknowledge and warrant that I hereby unconditionally and irrevocably release and hold harmless, and covenant not to file suit against any and all of the Released Parties relative to and/or reliance upon the tests, results, consultation, advice (medical, professional or otherwise) and information relayed, arising out of any affiliated health screening, associated tests and informational sessions at or from the Event. I understand and personally assume the risk and consequences of any affiliated WellBatavia Prevention Village Event screening and associated tests from the Event. By signing this Agreement, I consent to the use and disclosure of my Protected Health Information obtained at, or as a result of, the Event for treatment and health care operations. I further understand that my testing and screening results may be used for medical research, test validation, or education, after personal identifiers are removed and all Protected Health Information is de-identified. Refusal to permit the use of my data for research will not affect my test result(s). I can withdraw my consent at any time by sending a written notice of revocation of the consent to the WellBatavia Initiative. The undersigned agrees not to sue any of the Released Parties for any matter released under this Agreement and to pay the Released Parties’ attorneys’ fees and costs resulting from a breach of this Agreement by the undersigned. The undersigned agrees that if anyone else sues any of the Released Parties related to the actions of the undersigned while on the premises of the City of Batavia, the undersigned will indemnify and hold harmless the Released Parties against all damages, costs and their attorneys’ fees. The undersigned further agrees that (a) no promise, inducement or agreement not herein expressed has been made to the undersigned; (b) this Agreement contains the entire agreement between the parties hereto; (c) this Agreement may not be modified, except in a written instrument signed by an authorized representative of the Released Parties; and (d) if any portion of this Agreement is held invalid, the balance shall continue in full force and effect. PHOTOGRAPHIC RELEASE: I further give my full consent and permission to the WellBatavia Initiative Event, its affiliates, sponsors, successors, assigns and licensees the irrevocable right to use, for any purposes whatsoever and without any compensation, any photographs, videotapes, audiotapes and/or other recordings of me, my minor children and/ or representatives that are made during the course of the Event. This Waiver and Release Agreement and Photographic Release shall be construed under the laws of the State of Illinois. I understand that I have given up substantial rights by signing this Waiver and Release Agreement and Photographic Release, and have done so voluntarily without any inducement, assurance or guarantee being made to me and intend my signature to be a complete and unconditional release of liability to the greatest extent permitted by law.