Name *
Birth Date *
Birth Date
Address *
Phone *
If the participant is a minor, list parent or guardian information (Skip to line of work if not)
If the participant is a minor, list parent or guardian information (Skip to line of work if not)
Parent/Guardian Address
Parent/Guardian Address
Parent/Guardian Phone
Parent/Guardian Phone
1 being worst 10 being best
1 being worst 10 being best
By typing your full name, you acknowledge that you’ve read, understand and agree with the following forms; 1. Release of Liability and Assumption of Risk 2. Liability Waiver 3. Cancellation Policy 4. Refund Policy 5. Video/Photo Release Form
Today's Date *
Today's Date

Release of Liability and Assumption of Risk

Bell and Corter Chiropractic PC, AKA: True Potential Chiropractic (TPC)

In consideration of being permitted by TPC to participate in the Jose Rodrigues “A.P.E Shape” physical

activities and to use its facilities, I hereby agree to release, indemnify and discharge Bell and Corter

Chiropractic PC, AKA True Potential Chiropractic (TPC) with physical address located at 8283 Cirrus

Drive, Bld. #15, Beaverton, OR 97008, its agents, owners, landlord, shareholders, directors, partners,

employees, volunteers, manufacturers, participants, lessors, affiliates, its subsidiaries, related and

affiliated entities, successors and assigns the “RELEASED PARTIES,” on behalf of myself, my spouse,

my children, my parents, my heirs, assigns, personal representative and estate as follows:

1. I acknowledge that my participation in activities performed on premises of TPC’s leased space entail

known and unknown risks that could result in physical or emotional injury, paralysis, death, or damage

to myself, to property or to third parties. I understand that such risks simply cannot be eliminated

without jeopardizing the essential qualities of the activity. Other more serious risks exist as well.

Participants may fall, sprain or break wrists and ankles, and can suffer more serious injuries as well. In

any event, if you or your child is injured, you or your child may require medical assistance, at your own

expense. Furthermore, TPC employees and independent contractors have difficult jobs to perform. They

seek safety, but they are not infallible. They may give incomplete warnings or instructions, and the

equipment being used might malfunction.

2. I expressly agree and promise to accept and assume all of the risks existing in this activity. My

participation in this activity is purely voluntary, and I elect to participate in spite of the risks.

3. I hereby voluntarily release, forever discharge, and agree to defend, indemnify and hold harmless

RELEASED PARTIES 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 TPC’s equipment or facilities, including any

such claims which allege negligent acts or omissions of RELEASED PARTIES.

4. Should TPC or anyone acting on their behalf, be required to incur attorney’s fees and costs to enforce

this agreement, I agree to indemnify and hold them harmless for all such fees and costs.

5. I certify that I have adequate insurance to cover any injury or damage that I may cause or suffer while

participating, or else I agree to bear the costs of such injury or damage myself. I further certify that I am

willing to assume the risk of any medical or physical condition that I may have.

6. In the event that I file a lawsuit against TPC, I agree to do so solely in the State of Oregon and I further

agree that the substantive law of Oregon shall apply in that action without regard to the conflict of the

law rules of that state. I agree that if any portion of this agreement is found to be void or unenforceable,

the remaining portions shall remain in full force and effect.

7. I agree as an adult participant, or the Parent/Legal Guardian of a minor participant, in consideration of

being permitted to participate at TPCs premises, grant TPC, its parent subsidiaries, related and affiliated

entities, officers, directors, landlord, partners, shareholders, employees, agents, successors and assigns,

the irrevocable right and permission to photograph and/or record me or my child(ren)/ward(s) in

connection with TPC to use the photograph and/or recording for all purposes, including advertising and

promotional purposes, in any manner in any and all media now or hereafter known, in perpetuity

throughout the world, without restriction as to alteration. I waive any right to inspect or approve the

use of the photograph and/or recording, and acknowledge and agree that the rights granted to this

release are without compensation of any kind. All photographs and/or recordings are exclusive to TPC


8. I agree that if the participant is a minor, this Release of Liability and Assumption of Risk agreement is

made on behalf of that minor participant and that all of the releases, waivers and promises herein are

binding on that minor participant. I represent that I have full authority as Parent or Legal Guardian to

bind the minor participant to this agreement.

9. I agree that if the participant is a minor, I further agree to defend, indemnify and hold harmless TPC

(RELEASED PARTIES) from any and all claims or suits for personal injury, property damage or otherwise

which are brought by, or on behalf of the minor, and which are in any way connected with such use or

participation by the minor, including injuries or damages caused by the negligence of RELEASED

PARTIES, except injuries or damages caused by the sole negligence or willful misconduct of the party

seeking indemnity.

By signing this document, I acknowledge that if anyone is hurt or property damaged during my

participation in this activity, I may be found by a court of law to have waived my or the minor

participant’s right to maintain a lawsuit against TPC or any RELEASED PARTIES on the basis of any claim

from which I have released them herein. I have had sufficient opportunity to read this entire document.

I have read and understood it, and I agree to be bound by its terms.


Liability Waiver:

I, the undersigned, being aware of my own health and physical condition, and having knowledge that my participation in any exercise program may be injurious to my health, am voluntarily participating in physical activity with A.P.E. Shape.


Having such knowledge, I hereby release A.P.E. Shape, their representatives, agents, and successors from liability for accidental injury or illness which i may incur as a result of participating in the said physical activity. I hereby assume all risks connected therewith and consent to participate in said program.


I agree to disclose any physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in said fitness program.


Cancellation Policy

All cancellations must be received at least 24 hours before your training session in order to avoid being charged for your session. Clients who do not cancel with 24 hours notice will be charged for the cancelled session.


A.P.E Shape understands that emergencies happen. We will try to provide every client with the opportunity to reschedule short-notice cancellation with in two weeks of the original appointment (days and times are dependent on availability). The rescheduling of the short-notice cancellation only applies if A.P.E shape is notified prior to the session start time. No shows are not eligible for the rescheduling without charge.


Real Time Online sessions will be provided a brief recorded demonstration of their routine within 24 hours of the original set date and time. This is to include technical difficulties with your equipment, software or internet connection. No shows (no prior acknowledgment that you can not attend the online session) are not eligible for a recorded demonstration of the workout.


Refund Policy

A.P.E Shape strives to provide the best possible service to our clients. It is not our policy to refund any unused sessions. In the case, that it has been determined by a Licensed Physician that you are unable to complete any physical exercise(i.e. bed bound) we will honor your unused sessions until you have been cleared to exercise again. Otherwise, all sessions will expire 6 months after the original purchase date.


Video/Photo Release Form

I hereby grant A.P.E. SHAPE, LLC the irrevocable right and permission to use photographs and/or video recordings of me working out for their websites and in publications, promotional flyers, educational materials, derivative works, or for any other similar purpose without compensation to me.  


I understand and agree that such photographs and/or video recordings of me may be placed on the Internet.  I also understand and agree that I may be identified by name and/or title in printed, Internet or broadcast information that might accompany the photographs and/or video recordings of me.  I waive the right to approve the final product.  I agree that all such portraits, pictures, photographs, video and audio recordings, and any reproductions thereof, and all plates, negatives, recording tape and digital files are and shall remain the property of the University.  


I hereby release, acquit and forever discharge Jose Rodrigues and A.P.E. SHAPE, LLC, its current and former trustees, agents, officers and employees of the above-named entities from any and all claims, demands, rights, promises, damages and liabilities arising out of or in connection with the use or distribution of said photographs and/or video recordings, including but not limited to any claims for invasion of privacy, appropriation of likeness or defamation.


I hereby warrant that I am eighteen (18) years old or more and competent to contract in my own name or, if I am less than eighteen years old, that my parent or guardian has signed this release form below.  This release is binding on me and my heirs, assigns and personal representatives.