Acknowledgement and Waiver * At the Event, Professional Orthopedic and Sports Physical Therapy of NY, LLC and/or its affiliated entities (collectively, “PPT”) are making available injury assessments as a community service for participants in the Event. The injury assessment is designed to identify activities, training, exercise or actions that may increase the probability of injury (collectively, “Injury Assessment”). Said Injury Assessment may include, but may not be limited to, injury screening, stretching, taping, and wound care. Participant for him/herself (and, if applicable, on behalf of the Minor named below) and on behalf of Participant’s heirs, executors, administrators and assigns, certifies that he/she has read, understands and agrees to the terms of each of the following provisions:
1) Participant expressly acknowledges that the Injury Assessment provided by PPT does not constitute physical therapy, occupational therapy or athletic training services for which a physician’s order is required by the state of New York.
2) Participant acknowledges that participation in the Injury Assessment entails known and unknown risks that could result in physical injury, permanent disability and harm (“Risks”). Participant understands that the Injury Assessment may include, but is not limited to, injury screening, stretching, taping, and wound care, which may pose certain risks.
3) Participant hereby expressly agrees to: (i) voluntarily participate (or, if applicable, allow the Minor identified below to participate) in the Injury Assessment, despite the Risks; and (ii) accepts and assumes all such Risks related to the Injury Assessment.
4) Participant hereby releases, waives, discharges and covenants not to sue PPT, any of its members, officers, directors, partners, employees and agents, and their respective heirs, executors, administrators successors and assigns (the “Releasees”), with respect to any and all actions, causes of action, claims, demands, liabilities, losses, costs (including attorneys fees) or damages (collectively, “Losses”) resulting from or related to my participation (or, if applicable, the participation of the Minor named below) in the Injury Assessment, including, without limitation, Losses arising from the actual or alleged negligent acts or omissions of Releasees. Participant further agrees to indemnify and hold Releasees harmless from any Losses in the event that any lawsuit is commenced or threatened against them or any one of them.
5) Participant agrees that this Agreement shall be governed by the laws of the State of New York and is intended to be as broad as inclusive as is permitted by law and in the event that any provision of this Agreement is determined to be invalid or unenforceable for any reason, the balance of the Agreement shall not be affected or impaired in any way and shall continue in full legal force and effect.
Marketing HIPPA Likeness Form: Insert Full Name *
I being of full age and majority, do hereby consent to permit PPT to use, re-use, utilize and
disclose to the general public at large my testimonial, verbal or written statements, quotes, likeness, photographs, videorecorded
images, audio recordings, voice, name, pictorial images, biographical information, and/or other likeness of
myself (collectively, “Likeness”) in any internal and external media, including, without limitation, television, radio,
newspaper, Internet, publications, billboards, signs, websites, and social media accounts in conjunction with PPT
business efforts, marketing, advertising, promotional activities, publicity, materials, and/or programs (collectively, “Use of
Likeness”), regardless of the chosen medium for Likeness and Use of Likeness.
I do hereby acknowledge that I will not receive any payment or other consideration for PPT’s Use of Likeness, and I do
hereby further acknowledge that all such Use of Likeness, in whatever medium, is and shall remain the property of PPT.
I do hereby acknowledge that I have the right to revoke this consent at any time by sending a dated and signed letter to
the Privacy Officer at PPT stating that I revoke this consent. I understand that if I choose to revoke this consent it will
become effective on the day of the revocation of the consent, and any prior Likeness or Use of Likeness will not be
subject to the revocation of the consent. I understand that PPT will use its best effort to remove Likeness and Use of
Likeness from the applicable media, but fully understand that PPT makes no guarantee of complete removal therefrom.
I do hereby waive my right to inspect, review, and/or approve PPT’s Use of Likeness, and do hereby consent to allow PPT
to use and subsequently reuse Likeness in materially the same form in the media of PPT’s choice, in its sole and absolute
discretion.
I do hereby release and forever discharge PPT and its officers, directors, shareholders, members, partners, agents,
employees, subsidiaries, affiliates, related organizations, successors and assigns, of and from any and all manner of
actions, causes of action, suits, proceedings, accounts, controversies, agreements, promises, damages, judgments,
executions, claims and demands whatsoever, regardless of source or nature, whether known or unknown, in law or in
equity, against them or any of them, arising out of or in any way related to Likeness, Use of Likeness, and this Consent to
Use of Likeness.
By signing this consent, I do hereby acknowledge that I have read the foregoing, or have had it read to me, and I fully
understand its contents and significance, and I have signed this consent voluntarily, without recourse or promise of any
kind, and agree to be bound hereby.
I ACKNOWLEDGE THAT (i) I HAVE READ AND FULLY UNDERSTAND THIS AGREEMENT; (ii)
BY SIGNING THIS AGREEMENT I AM WAIVING AND RELEASING CERTAIN LEGAL RIGHTS;
AND (iii) I AM SIGNING THIS DOCUMENT FREELY AND VOLUNTARILY.
