iStroll Health Screen & Release Agreement

Release of Liability

I, the undersigned, hereby release iStroll, LLC (iStroll Tampa & iStroll Socially) and the owner Tess Partridge from any liability or claims for injury, illness, or property damage that I sustain and/or cause during my participation or sustained by my son/daughter/minor in my care participating in this event, program or other which is in any way related.

I expressly accept and assume all of the risk inherent in this activity or that might have been caused by the negligence of Releasees. Releasees are defined as partners, sponsors, officers, members, agents, employees and any other organization, entities, and individuals who are serving iStroll including all volunteers assisting with programs, events or other iStroll activities.

I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless Releasee from any and all claims, demands, or causes of action which are in any way connected with my participation in this activity, or my use of their equipment, facilities, or public grounds programs/events take place, arising from negligence. This release does not apply to claims arising from intentional misconduct.

Participants

Name

Do you grant us permission to release images of you/your family on social media/the internet? Circle:

Yes No

Primary Participant/Parent/Guardian Check:
By Checking Box You Agreed To Our (Terms)
I Understand the Terms and Conditions.

Name

Phone

Sex
Male Female

DOB

Emergency Contact

Phone

AIM: to identify those individuals with a known disease, or signs or symptoms of disease, who may be at a higher risk of an adverse event during physical activity/exercise. This checklist is self administered and self evaluated.

1. Have you ever suffered or been told by a doctor that you have suffered a stroke?
Yes No

2. Has your doctor ever told you that you have a heart condition?
Yes No

3. Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?
Yes No

4. Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?
Yes No

5. Have you had an asthma attack requiring medical attention at any time over the last 12 months?
Yes No

6. If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months?
Yes No

7. Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?
Yes No

8. Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?
Yes No

9. Are you pregnant or is there a chance you could be pregnant?
Yes No

IF YOU ANSWERED ‘YES’ to questions 1 - 9, we recommend you obtain written medical clearance/approval from a GP or appropriate allied health professional stating your are able to safely undertaking physical activity/exercise in our clubs. IF YOU ANSWERED ‘NO’ to all questions, and you have no other concerns about your health, you may proceed to undertake moderate/high intensity physical activity/exercise.

I believe that to the best of my knowledge, all of the information I have supplied within this tool is correct. If, throughout the duration of my participation in iStroll any of the questions I answered "No," change to "Yes" I will inform my instructor and seek medical clearance/approval from the appropriate allied health proffesional before continuing any iStroll activities.

By Checking Box You Agreed To Our Terms
I Understand the Terms and Conditions.