ACKNOWLEDGEMENT & RELEASE OF LIABILITY , AND HIPAA CONSENT

Acknowledgement & Release of Liability
I, on behalf of myself, request authorization to participate in the Wellness Program offered by Weltrio LLC (hereafter “Wellness Program”). I acknowledge that my participation in the Wellness Program is expressly conditioned on my agreement to each of the terms of this document. I acknowledge and agree as follows:

1. As the participant, I recognize and acknowledge that there are risks of physical injury with any physical exercise, sport, wellness, and/or recreational activities and I agree to assume the full risk of any injuries (including death), damages, or loss which I may sustain as a result of participating in any and all activities arising out of, connected with, or in any way associated with my use of the Wellness Program. I acknowledge that participation in the Wellness Program is voluntary.
2. I, on behalf of myself, do hereby fully release and discharge Weltrio, and their agents, employees and the sponsors, and those whose facilities are being used for this program (collectively, the “Released Parties”) from any and all liability, claims, and causes of action from injuries or illness (including death), damages or loss which I may have or which may accrue to me on account of participation in all activities. This is a complete and irrevocable release and waiver of liability. Specifically, and without limitation, I, on behalf of myself, hereby release the Released Parties from any liability, claim, or cause of action arising out of
the Released Parties’ negligence. I, on behalf of myself, covenant not to sue the Released Parties for any alleged liabilities, claims, or causes of action released here-under.
3. I further agree to indemnify and hold harmless and defend the Released Parties from any and all claims resulting from injuries or illness (including death), damages, or loss, including, but not limited to attorneys’ fees, sustained by me arising out of, connected with, or in any way associated with, the Wellness Program and Released Parties.
4. In the event of any emergency, I authorize the Released Parties to secure from any licensed hospital, physician and/or medical personnel any treatment deemed necessary for my immediate care and agree that I will be responsible for payment of any and all medical services rendered.
5. I understand that I should consult with a physician before I undertake any wellness program. I certify that I am in sufficient physical condition to participate in the Wellness Program and that I will carefully follow any restrictions or medical advice as it pertains to my participation in such activities. I have read and fully understand this Acknowledgement and Release of Liability set forth above, including the permission to secure medical treatment and the release of all claims, including claims for the negligence of the Released Parties. I am 18 Document Ref: QM4JH-YPTTF-CF3CX-E72S6 Page 1 of 2 years old or older. I understand that my signed waiver will be retained in my Weltrio wellness program file. This document is binding upon me, my personal representatives and anyone else entitled to act on my behalf.

HIPAA Acknowledgement and Consent Form
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy
regarding my protected health information.

Basic Principle of HIPAA
A major purpose of the Privacy Rule is to define and limit the circumstances in which an individual’s protected health information
may be used or disclosed by covered entities. A covered entity may not use or disclose protected health information, except
either: (1) as the Privacy Rule permits or requires; or (2) as the individual who is the subject of the information (or the
individual’s personal representative) authorizes in writing.

I understand that for more information about the uses and disclosures of my health information, I may click
here: https://www.hhs.gov/sites/default/files/privacysummary.pdf .
For Notice of Privacy Practices, click here: https://www.ecu.edu/csdhs/ecuphysicians/pharmacy/upload/HIPAANoticePrivacyPractices.pdf

I have been given the opportunity to review the Notice of Privacy Practices prior to signing this consent below. I may contact Weltrio at any time to obtain a current copy of the Notices of Privacy Practices.
I understand that I may request in writing to revoke this consent at any time.
Weltrio; 104 SW Dorian Ave #1983; Pendleton, OR 97801

W are required by law to maintain the privacy of, and provie individuals with, this notice of our legal duties and privacy practices with respect to protected health information.  If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number.

This signature is only acknowledgement that you have received this ntoice of our Privacy Practices.