Release of Liability, Waiver and Indemnity Agreement

This Agreement must be completed in full before you can take part in the Program.

First Name

Last Name

The Red Deer Primary Care Network’s Health Basics program includes supervised exercise that may help patients who have chronic disease(s). These exercises support your health and physical skill, while keeping you safe. The class exercises are supervised and monitored by a healthcare provider. 

Taking the Program is voluntary. The Program does not replace medical advice. You can speak to your doctor about the program before you sign up. The staff will explain signs and symptoms that will tell you to stop or slow down. If you have pain or run into trouble during the Program, stop the Program right away and tell the Program staff.

I understand the benefits and risks involved in the Program. I freely accept and fully assume all such risks, and the possibility of personal injury and damage or loss to personal property because of taking part in the Program. In consideration of Red Deer Primary Care Network offering the activity, I agree as follows:
  1. To waive all claims that I have or may have in the future against the Provider and its Board Members, employees, agents, volunteers, and independent contractors (collectively referred to as “the Releasees”), as a result of my participation in the Program due to any cause including negligence, breach of contract, or any other duty care.
  2.  To  hold harmless and indemnify the Provider and Releasees from any and all liability for any damage to the property of, or personal injury to any third party, resulting from my participation in the Program; and ,
  3. That this agreement shall be effective and binding upon myself, the participant named above, my heirs, next of kin, executors, administrators, assignees, and representatives in the event of death or incapacity.
In entering into this agreement, I am not relying upon any oral or written representation or statements made by the Provider and Releasees other than what is set forth in this Agreement. I also understand that I can seek independent legal advice before entering into this agreement.

Today's Date



Adapted from Alberta Health Services form 18964(2013-04)


Powered by SimpleSurvey