Dragonfly Wellness Center, Inc. 176 Jackson Road Devens, MA

RELEASE & WAIVER OF LIABILITY

Dragonfly Wellness Center, Inc. 176 Jackson Road Devens, MA RELEASE & WAIVER OF LIABILITY I, __________________________________ (please print name), would like to participate in activities and classes offered by Dragonfly Wellness Center, Inc. at its facility located at 176 Jackson Road, Devens, MA. I understand that these classes and activities, led by a program instructor, will require some physical exertion, which I may find strenuous and/or may cause me physical injury, and I am fully aware of and accept the risks and hazards involved. I understand that it is my responsibility to inform the program instructor of any previous conditions, ailments, injuries, surgeries or physical limitations prior to participating in this program. I understand that it is my responsibility to notify the program instructor if I sustain any injury or develop any medical condition requiring medical treatment prior to participation in a class. I understand that it is my responsibility to notify the program instructor immediately if I experience any pain or discomfort during a class. I understand that it is my responsibility to slow down or end my participation based on my physical condition both before and during any activities at the Center. I agree that it is my responsibility to consult with a physician prior to and regarding my participation in these activities and classes. I understand that these activities and classes are not intended to provide or take the place of medical advice or treatment. In consideration of being permitted to participate in these activities and classes and to enter upon the Center’s facility at 176 Jackson Road, Devens, MA, I agree to assume full responsibility for any risks, conditions, injuries or damages, known or unknown, both to my person or my property, which I may incur or aggravate as a result of my participation in these activities and classes and/or my entering and being on the premises. I, and on behalf of my heirs, executors and assigns, hereby release and hold harmless Dragonfly Wellness Center, its agents, officers and employees, and program instructors leading the classes and activities at Dragonfly Wellness Center, from and against any and all liability, loss, expense (including reasonable attorneys’ fees) or claims for injury or damages resulting from or related to my participation in Dragonfly Wellness Center’s classes or activities. I affirm that I have read this document and that I have had sufficient time to consider its terms and further that I would not sign this document if I did not understand its terms. I acknowledge that Dragonfly Wellness Center, Inc. is relying on this document for purposes of allowing me to participate in activities and classes offered by Dragonfly Wellness Center, Inc.

Participant Signature _________________________________ Date________________________

If participant is under age 18, authorization and consent to participate in this program is hereby provided by: Signature ___________________________________

Date _________________________ Relationship to Participant__________________________________