Poppy Life Care & Hoag Programs Terms, Conditions & Waiver Policy
1. Consent to Exchange Information and Release of Records
I authorize staff and/or authorized representatives of Hoag Center for Healthy Living, Hoag affiliates, member agencies and programs listed below to disclose & exchange among themselves, confidential information and records about myself and family members listed below, in order to assist me/us in developing and implementing a comprehensive individual/family service plan.
- Hoag Mental Health Center
- Hoag Affiliate
- Daniele Jaramillo, RN BSN PHN CLE
- Susan G. Komen
- CHOC – PODER
- OC Vital Brain Aging Program
- Council on Aging
- CMFRC: Human Options, Girls Inc, Children's Bureau, MOMS Orange County & The Raise Foundation
- Public Law Center
- Orange Bar Foundation
- Big Brother Big Sister
- Be the Change Yoga
- Cancer Kinship
- Poppy Life Care
This information may include educational, medical, psychological, employment, social services, and family history. I understand that these agencies will not release any of my/our records or information about me or my family to organizations or individuals not listed above without first obtaining my written consent. This release applies to the following individuals: self/mother/father/partner.
I understand that I have a right to review my records and that this consent is voluntary and I may withdraw it in writing at any time. The withdrawal of my consent would not apply to information previously shared between member agencies. I further understand that this consent expires within a year from the date of signature or when my family and I no longer receive services from the Center for Healthy Living, whichever comes first. The information contained in this consent form may be shared or given to the abovementioned agencies for purpose of identifying additional services. My signature indicates that I understand the above information. A photocopy of this document is as valid as original.
2. Release for Participation in Event, Activity or Program
In exchange for participation in the customized Yoga program, organized by Poppy Life Care Foundation, in the State of California, I hereby agree as follows:
I and anyone claiming on my behalf release and forever discharge Company and its affiliates, successors and assigns, officers, employees, representatives, partners, agents and anyone claiming through them (collectively, the “Released Parties”), in their individual and/or corporate capacities from causes of action of any nature and kind, known or unknown, which I may have against Company or any Released Parties arising out of or relating to any injury, loss or damage to person and property that may be sustained as a result of participation in the Activity (“Claims”).
I understand that participation in the Activity may involve unintended risks, including risk of physical or psychological injury, pain, suffering, illness, and I assume all related risks and voluntarily participate in the Activity.
I agree to indemnify Company against any and all claims, actions, lawsuits, damages, and judgments, including attorney’s fees, arising out of or relating to my participation in the Activity.
This Release for Participation in Event or Activity (“Release”) shall not be in any way construed as an admission by the company that it has acted wrongfully with respect to me or any other person, that it admits liability or responsibility at any time for any purpose, or that I have any rights whatsoever against the Company.
This Release shall be binding upon the parties and their respective heirs, administrators, personal representatives, executors, successors and assigns. I have the authority to release the Claims and have not assigned or transferred any Claims to any other party. The provisions of this Release are severable. If any provision is held to be invalid or unenforceable, it shall not affect the validity or enforceability of any other provision. This Release constitutes the entire agreement between the parties and supersedes any prior oral or written agreements or understandings between the parties concerning the subject matter of this Release. This Release may not be altered, amended or modified, except by a written document signed by both parties. The terms of this Release shall be governed by and construed in accordance with the laws of the State/Commonwealth of California.
I have carefully read and fully understand all the provisions of this Release and am freely, knowingly and voluntarily entering into this Release.
I hereby give permission for images of my child, myself and/or family, captured during the Yoga program through video, photo, and digital camera, to be used solely for the purposes of Poppy Life Care Foundation (Organization) promotional material, marketing and/or publications, and waive any rights of compensation or ownership thereto.
3. Waiver of Liability 2019
By signing this document, you will waive certain legal rights. Please read carefully!
I certify that I am in good physical condition and able to use the facilities and equipment and to participate in exercise activities available at Hoag Memorial Hospital Presbyterian-Hoag Center for Healthy Living(the “CHL”). I understand that it is advisable to obtain medical release and my doctor’s approval prior to initiation of any exercise program.
Potential Risks and Hazards
I understand that physical activity, by its very nature, carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. The CHL has facilities and provides activities such as Yoga, Zumba, Barre, and other aerobic activities. Some of these may involve strenuous exertions of strength using various muscle groups, some involve quick movements involving speed and change of direction and others involve sustained physical activity which places stress on the cardiovascular system. The specific risks vary from one activity to another, but the risks range from (1) minor injuries such as scratches, bruises, and sprains, to (2) major injuries such as eye injury or loss of sight, joint or back injuries, fractures, heart attacks, and concussions, to (3) catastrophic injuries including paralysis and death.
I am fully aware of the risks and hazards connected with use of the CHL, whether specifically listed here or not, and I hereby voluntarily elect participate in exercise classes at the CHL, knowing that the use of the facilities at CHL may be hazardous to my person and property. I understand that qualified instructors are available to assist me in learning to use exercise equipment safely. I understand that if I have questions about possible hazards, it is my responsibility to seek additional information from a staff member at the CHL prior to signing this document.
Assumption of Risk, Waiver of Liability
In consideration for being permitted to use the CHL facilities, I voluntarily agree for myself, my family, heirs, executors, and administrators to the following:
TO ASSUME FULL RESPONSIBILITY FOR ANY RISKS OF LOSS, 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 using the CHL facilities.
TO RELEASE, WAIVE, HOLD HARMLESS, DISCHARGE, AND COVENANT NOT TO SUE the CHL, its directors, officers, employees, affiliates, agents, and staff (hereinafter referred to as “Releases”)from any and all liability, claims, actions, demands, expenses, attorney fees, breach of contract actions,breach of statutory duty or other duty of care, warranty, strict liability actions, and causes of action whatsoever, that I might now have or may acquire in the future, arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or to any property belonging to me while using the CHL facilities including, but not limited to, any claim that the act or omission complained of was caused in whole or in part by the negligence or carelessness of the releases.
Compliance with Rules
I agree to comply with any rules and any Hoag policies governing the use of the CHL facility and equipment which may be in effect from time to time.
Governing Law and Severability
I hereby further agree that this Waiver of Liability shall be construed in accordance with the laws of the State of California, and that if any portion is deemed to be invalid, the remainder of this Waiver of Liability will still be binding and enforceable.
Acknowledgement of Understanding
In signing this Waiver of Liability, I acknowledge and represent that I have the document in full, that I understand it and sign it voluntarily, and that this document constitutes the entire agreement between me and Hoag Memorial Hospital Presbyterian-Hoag Center for Healthy Living regarding my use of the CHL, and that any oral representations, statements, or inducements apart from the foregoing written document shall not be considered a part of this agreement, and that I execute this Waiver of Liability for full, adequate, and complete consideration fully intending to be bound by the same.
If you should have any questions about the hazards and risks associated with the CHL or with this document, please contact a CHL staff member.
I further certify that I am either at least eighteen (18) years of age and fully competent, or the parent or legal guardian of the Participant and fully competent.