WELLNESS PROGRAMS PARTICIPANT TERMS AND CONDITIONS AND CONSENT FORM

RISKS AND BENEFITS

I am aware that anyone who smokes, has poor dietary habits, has ever had elevated blood pressure, presently does not exercise, has ever had cardiac (heart) problems, is overweight, has diabetes, has any other cardiovascular problems, or is susceptible to orthopedic problems is at greater risk while exercising. I am also aware that exercise can have risks which in certain instances may be harmful and even result in death. I am also aware that quitting smoking, changes in diet, and exercise may offer health benefits such as improved cardio respiratory function, energy, strength, greater ability to lose or maintain weight, and protection against disease.

I understand that I should consult with my personal physician before I begin or continue any nutrition or exercise programs, including the programs available to me through Employee Services, Inc. and its business associates (collectively “ESI”).

CONFIDENTIALITY AND PERSONAL INFORMATION

I understand and agree that

  • ESI may collect information related to my personal fitness and health information in order to provide me with the nutrition and fitness related services through the ESI programs;
  • ESI may release such information to its business associates to administer the programs, services, and activities in which I am involved;
  • it is my sole responsibility, in consultation with a physician or other health/fitness professional of my choosing, to determine which programs offered by ESI are suitable for me given my personal health/fitness condition; and
  • ESI shall not share or disclose my specific information with or to my employer, its subsidiaries and affiliates or any of their respective owners, officers, directors, or employees, but may provide general information concerning my participation and the effectiveness of the programs in which I chose to participate.

RELEASE

My use of this web site and participation in programs provided by ESI and/or my employer are voluntary and at my own risk. In consideration for being able to use the web site or being permitted to participate in these programs, I, on behalf of myself and my heirs, executors, administrators, and assigns, hereby release, discharge, and covenant not to sue in the future, my employer, ESI, their subsidiaries, successors, assigns, affiliates and business associates, and any/all of their directors, officers, employees, and agents with respect to any and all claims, demands, actions, or causes of action whatsoever, present or future, arising out of or related to my use of this web site or participation in the programs provided by ESI. This release specifically includes, but is not limited to, exercise or increased activity, entry of data or other information, fitness testing, dietary changes, equipment usage, class participation, indoor or outdoor activities, recreational team participation, or any other activity while participating in the programs.

I agree that if a legal dispute arises concerning my participation in programs offered by ESI, I will attempt to settle the dispute through mediation, and if mediation is not successful, will submit the dispute to binding arbitration conducted in Allegany County, New York through the American Arbitration Association. I further agree that the laws of New York shall apply in any such matter.

AUTHORIZATION


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