Participant Agreement |
Health Risks & Liability |
Scope of Practice and Services |
Massage Therapy Matters aims to be exceptional, therefore, MTM services may record for content and training. Knowingly, I grant total permission to record the appearance, voice, and likeness of my person and property.
A/V Consent: Massage Therapy Matters “MTM” aims to offer exceptional service, therefore, massage may be recorded for content and training. I grant full permission to record the appearance, voice, and likeness of my person and property. At the sole discretion of MTM, I agree to waive full rights to Massage Therapy Matters to alter, reuse or distribute any image, video, and media of my person with no compensation provided.
I, the participant, hereby grant MTM permission to use my likeness or the likeness in photographs, videos recordings, or electronic images in any and all of its publications, including website entries and social media, without payment or any other consideration. I understand and agree that these materials will become the property of MTM and will not be returned. I hereby irrevocably authorize MTM to, edit, alter, copy, exhibit, publish or distribute these images and videos for purposes of publicizing their programs, marketing or for any other lawful purpose. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my likeness appears.
I hereby grant ownership rights and relinquish any property rights of any recording, image, duplication, alteration, video, or media of my person or belongings in order for MTM to have full rights of ownership, usage, distribution or selling of my person, likeness, and/or belongings with no compensation provided to me indefinitely at the sole discretion of MTM.
Practitioner/Clinic Name: ____________________ Health Information Contact Information: ________________________ (page 1 of 2) Client Contact Information Client Name: ___________________________________ Date: ____________ Date of Birth: ____________ Gender: ____________ Address: _________________________________________________________________________________ Phone: _______________________________________ Email: ___________________________________ Referred by: ___________________________________ Emergency contact: _____________________________ Phone: ___________________________________ Physician/Health-care Provider name: __________________________ Phone: ____________________ Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)? Yes ☐ No ☐ Do you have a physician referral/prescription? Yes ☐ No ☐ Are you seeking insurance reimbursement? Yes ☐ No ☐ If yes, please complete the Billing Information form. Type of insurance coverage for this claim: Car Collision Worker’s Compensation Private Health Massage Information Have you ever received professional massage/bodywork before? Yes ☐ No ☐ How recently? ___________________________________ What types of massage/bodywork do you prefer? ___________________________________ What kind of pressure do you prefer? Light Medium Firm What are your goals/expected outcomes for receiving massage/bodywork? _________________________________________________________________________________________ _________________________________________________________________________________________ How do you feel today? ______________________________________________________________________ List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.): ______________________________________________________________________________________________ ______________________________________________________________________________________________ Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)? Yes No Explain: ______________________________________________________________________________________________ ______________________________________________________________________________________________ List the medications you currently take: ______________________________________________________________________________________________ ______________________________________________________________________________________________ Are you wearing contacts? Yes ☐ No ☐ Are you wearing dentures? Yes ☐ No ☐ Are you wearing a hairpiece? Yes ☐ No ☐ Are you pregnant? Yes ☐ No ☐ Associated Bodywork & Massage Professionals MEMBER Practitioner/Clinic Name: ____________________ Health Information Contact Information: ________________________ (page 2 of 2) Health History Have you had any injuries or surgeries in the past that may influence today’s treatment? ______________________________________________________________________________________________ Circle any of the following health conditions that you currently have (If you are unsure, please ask): blood clots, infections, congestive heart failure, contagious diseases, pitted edema Please answer honestly, as massage may not be indicated for the above conditions. Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Current Past Muscle or joint pain _____________________________________ Current Past Muscle or joint stiffness _____________________________________ Current Past Numbness or tingling _____________________________________ Current Past Swelling _____________________________________ Current Past Bruise easily _____________________________________ Current Past Sensitive to touch/pressure _____________________________________ Current Past High/Low blood pressure _____________________________________ Current Past Stroke, heart attack _____________________________________ Current Past Varicose veins _____________________________________ Current Past Shortness of breath, asthma _____________________________________ Current Past Cancer _____________________________________ Current Past Neurological (e.g. MS, Parkinson’s, chronic pain) _____________________________________ Current Past Epilepsy, seizures _____________________________________ Current Past Headaches, Migraines _____________________________________ Current Past Dizziness, ringing in the ears _____________________________________ Current Past Digestive conditions (e.g. Crohn’s, IBS) _____________________________________ Current Past Gas, bloating, constipation _____________________________________ Current Past Kidney disease, infection _____________________________________ Current Past Arthritis (rheumatoid, osteoarthritis) _____________________________________ Current Past Osteoporosis, degenerative spine/disk _____________________________________ Current Past Scoliosis _____________________________________ Current Past Broken bones _____________________________________ Current Past Allergies _____________________________________ Current Past Diabetes _____________________________________ Current Past Endocrine/thyroid conditions _____________________________________ Current Past Depression, anxiety _____________________________________ Current Past Memory Loss, confusion, easily overwhelmed _____________________________________ Comments: ______________________________________________________________________________________________ ______________________________________________________________________________________________ Consent for Treatment If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Understanding all of this, I give my consent to receive care. Client Signature: _____________________________________________________________ Date: ____________ Parent or Guardian Signature (in case of a minor): ___________________________________ Date: ____________
Liability: Massage Therapy Matters, hereby referred to as “MTM”, and its encompassed entities of Massage Therapy Matters, Massage Message, and Massage-Yoga Retreat and its direct or indirect subsidiaries or affiliates, employees, contractors, officers, directors, agents, representatives, managers, teachers, members, sponsors, volunteers and any other entity or person acting on its behalf, and all of its successors and assigns and/or those otherwise associated with or authorized by Massage Therapy Matters. Massage Therapy Matters may organize, lead, teach or otherwise provide massage therapy, stretching, wellness instruction, yoga, seminars, talks, competitions, challenges, and related services at which, referred to throughout as “services” on a contract basis for “Company” assigned persons hereby referred to as “Participants”. Services may include hands-on exercises, physical interaction, manual manipulation, verbal instruction or printed material provided related to health and fitness. I understand that by participating in the services, to the extent that they include massage or yoga classes, I have enrolled in a program of intense physical exercise and activity which may include manual manipulation of soft tissue, movement stretching, anaerobic and aerobic conditioning, weight training, exercises, suspension training and/or the use of other conditioning equipment. I hereby release Massage Therapy Matters from any and all claims, demands, causes of action, responsibility and/or liability whatsoever by any persons for any property loss, damage, personal injury, or death, arising from or connected with my participation in the services, including but not limited to that liability arising from any negligent acts of any person, including but not limited to MTM or other participants in the services. I further release MTM from any claims, demands, causes of action, responsibility and/or liability arising out of or connected with any defects or dangerous conditions on the premises where Services are held. I further release the MTM from any claims, demands, causes of action, responsibility and/or liability arising out of my or any other person’s use of the equipment and/or participation in the services. I fully understand that my participation in the services entails a risk of injury and I hereby release the MTM from any liability now or in the future for injuries including, but not limited to, heart attacks, strokes, fainting, muscle strains, pulls or tears, soft tissue injury, ligament or tendon injury, broken bones, shin splints, heat prostration, knee/lower back/foot injuries, and any other illness, soreness, injury or death, however, caused, occurring during or after my participation in the services. I do hereby further declare myself to be physically sound and suffering from no condition, impairment, disease, infirmity, or other illness that would prevent my participation or use of equipment or machinery. I do hereby acknowledge that I have been informed of the need for a physician’s approval for my participation in services or related activity or in the use of equipment, tools, or machinery. I also acknowledge that it has been recommended that I have a yearly or more frequent physical examination and consultation with my physician as to physical activity and the use of equipment so that I might have their recommendations concerning these services and equipment use. I acknowledge that I have either had an examination and been given permission to participate or that I have decided to participate in the activity and use of equipment without the approval of my physician and hereby assume all responsibility for my participation and activities and utilization of equipment and machinery in my activities. I acknowledge the receipt and sufficiency of consideration in connection with the above releases, indemnifications and hold harmless provisions. I hereby affirm that I have read and fully understand and agree to the above.
Scope of Practice: Licensed massage therapists (LMT) offer a voluntary activity for participants (referring to patrons and staff of the Company, and to any other individual within the area as approved by the company, collectively known as participants. MTM does not guarantee any minimum number of participants, therefore, it is the responsibility of the company to maintain full participation. MTM provides self-contracted therapist(s), equipment, and essentials to perform the service for the above-designated timeframe. MTM provides periodic text updates regarding the status of therapists. Kindly mention any updates, feedback or questions anytime. Massage therapy services are independent of services provided by the company.; Company shall provide adequate working space on the premises to perform the services (general guide 6 square feet consistently free of obstacles). All participants must sign an MTM | Release of Liability and Rights Waiver agreeing to, and thereby releasing the MTM from all liabilities regarding the services, stating that every participation is voluntary, and the participant is responsible for the risks and outcomes that may arise. The company is responsible for screening the participants for contraindications to massage therapy and whether the individuals are appropriate to participate in the said services regarding a safe space for massage, recent hygiene, and respect for therapeutic boundaries. LMT, clients, guests, patients, or participants may terminate service at any time, with just cause. The company certifies that all contractors who will be providing massage therapy services under the terms of this agreement are validly licensed, liability insured, and hold applicable state permits, and are consistent with the standards and scope of the profession. Documentation may be obtained upon request. Modifications to this agreement are not binding unless approved by both parties in writing.
Expressed A/V Waiver: Massage Therapy Matters “MTM” aims to offer exceptional service, therefore, massage may be recorded for content and training. I grant full permission to record the appearance, voice, and likeness of my person and property. At the sole discretion of MTM, I agree to waive full rights to Massage Therapy Matters to alter, reuse or distribute any image, video, and media of my person with no compensation provided. I, the participant, write my own name to affirm expressed consent to services and agree to MTM’s release of liability and rights located hereon.
Massage Therapy Consent to risk: I am voluntarily participating in the services entirely at my own risk. I am aware of the risks associated with these services, which may include, but is not limited to, physical or psychological injury, pain, suffering, illness, disfigurement, temporary or permanent disability (including paralysis), economic or emotional loss, and death. I understand that these injuries or outcomes may arise from my own or others' negligence, conditions related to travel, or the condition of the services provided. Nonetheless, I assume all related risks, both known or unknown to me, of my participation in services, including travel to, from and during and acknowledge services may involve a test of a person's physical and mental limits and may carry with it the potential for dynamic homeostasis, death, serious injury, and property loss. The risks may include, but are not limited to, those caused by terrain, facilities, temperature, weather, lack of hydration, condition of participants, equipment, vehicular traffic and actions of other participants, volunteers, spectators, officials and representatives of Massage Therapy Matters. Therapeutic massage is intended to reduce stress and tension. If experiencing unease, nausea, pain, or discomfort immediately inform the therapist; adjustment to the pressure applied, the position of your body and placement of touch can be made. I, participant, willingly accept any risks of massage hoping to obtain a benefit(s) that may result. We can stop the treatment at any time for any reason. Massage is not a substitute for medical care. Treatment and practice of any kind involve risk of injury, including swelling, bruising or pain. I understand that yoga includes physical movements as well as an opportunity for relaxation, stress re-education, and relief of muscular tension. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body, discontinue the activity, and ask for support from the instructor. I assume full responsibility for any and all damages, which may incur through participation. Services are not a substitute for medical attention, examination, diagnosis or treatment. Services, including massage and yoga, are not recommended and are not safe under certain medical conditions. By signing, I affirm that a licensed physician has verified my good health and physical condition to participate in such a fitness program. In addition, I will make the instructor aware of any medical conditions or physical limitations before class. If I am pregnant, become pregnant or I am post-natal or post-surgical, my signature verifies that I have my physician's approval to participate. I also affirm that I alone am responsible to decide whether to practice yoga and participation is at my own risk. I hereby agree to irrevocably release and waive any claims that I have now or may have hereafter against MTM, et al. I have read and fully understand and agree to the above terms of this Agreement and Release of Liability. I am signing this agreement voluntarily and recognize that my signature serves as complete and unconditional release of all liability to the greatest extent allowed by law in the State of Utah.
Rights: I acknowledge that Massage Therapy Matters and their directors, officers, volunteers, representatives, and agents are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or massage on behalf of Massage Therapy Matters. I, the participant, agree to indemnify and hold harmless Massage Therapy Matters against any and all claims, suits or actions of any kind whatsoever for liability, civil rights, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney's fees and any related costs, including release for negligence, on the part of Massage Therapy Matters, its agents, and representatives, if litigation arises pursuant to any claims made by me or by anyone else acting on my behalf. If Massage Therapy Matters incur any of these types of expenses, I agree to reimburse Massage Therapy Matters in full. In the event that any damage to equipment or facilities occurs as a result of my or my family's willful actions, neglect or recklessness, I acknowledge and agree to be held liable for any and all costs associated with any actions of neglect or recklessness. In consideration of the risk of injury while participating in therapeutic massage care ("massage”), and the right to participate in the massage, I hereby, for myself, my heirs, executors, administrators, assigns, or personal representatives, knowingly and voluntarily enter into this waiver’s terms and release of liability and full waiver of all rights to any image, video, and media of my person. I hereby waive any and all rights, claims or causes of action of any kind whatsoever arising out of my participation in the massage, and do hereby release and forever discharge Massage Therapy Matters. currently located in Park City Utah 84098, their affiliates, managers, members, agents, contractors, attorneys, volunteers, heirs, representatives, predecessors, successors and assigns, for any physical or psychological injury, including but not limited to illness, paralysis, death, damages, economic or emotional loss, that I may suffer as a direct result of participation in any service of Massage Therapy Matters, including traveling to and from an event related to this massage. In the event that I should require medical care or treatment, I agree to be financially responsible for any and all costs incurred as a result of such diagnosis, treatment, and/or followup indefinitely. I am aware and understand that I should carry my own health insurance. I, the participant, affirm that I am older than the age of 18 years, or have parental consent present with parental written name and that I am freely signing an agreement with Massage Therapy Matters. I certify that I have read this agreement, that I fully understand its content and that this release cannot be modified orally. I am aware that this is both a release of liability and release of rights to any image, video, and media of my person obtained by Massage Therapy Matters. This release agreement is a contract that I, the participant, am entering into by writing the name of my own free will.
Agreement: I acknowledge that I have carefully read this waiver and release and fully understand that it is a release of liability and rights to any image, video, and media of my person.. I expressly agree to release and discharge massage therapy matters and all of its affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns, from any and all claims or causes of action and I agree to voluntarily give up or waive any right that I otherwise have to bring a legal action against massage therapy matters for personal injury or property damage. This agreement was entered into at arm's-length, without duress or coercion, and is to be interpreted as an agreement between the two parties of equal bargaining strength. Both the participant, and Massage Therapy Matters agree that this agreement is clear and unambiguous as to its terms, and that no other evidence will be used or admitted to alter or explain the terms of this agreement, but that it will be interpreted based on the language in accordance with the purposes for which it is entered into. I, my heirs, legal representatives, civil or criminal, shall forever release, waive, discharge and covenant negligence or other acts of Massage Therapy Matters LLC and its direct or indirect subsidiaries or affiliates, employees, contractors, officers, directors, agents, representatives, managers, teachers, members, sponsors, volunteers and any other entity or person acting on its behalf, and all of its successors and assigns and/or those otherwise associated with or authorized by Massage Therapy Matters, known herein as “Massage Therapy Matters”, "MTM”, “Massage Message” “MM”, “Massage-Yoga Retreat”, “M-Y Retreat”, and “MYR”.
Massage Therapy Matters Utah Registration Form
Registering for: Ballet/ Contemporary Polynesian Hip Hop Aerial
Disclosure and Release Form
We are delighted to welcome you to Massage Therapy Matters! Please read and complete this form.
1. By choosing to participate in any dance class, workshop or clinic, you voluntarily, knowingly and expressly
assume the risk of injury. The following guidelines may help you to reduce that risk:
a. Listen to and follow your instructor carefully b. Work gently, respecting your body’s abilities and limits c. If you are unsure how to perform any movement, ask your instructor 2. Consult your physician before undertaking any exercise program. Inform your instructor of any health condition(s) that may be affected by your dance practice or yoga, Barre, dance, aerial or Pilates classes. You represent and warrant that you are physically fit, and have no medical condition that would prevent your full participation in any class offered at Massage Therapy Matters. 3. In consideration for your participation in any dance class, workshop and/or event, and by signing this form, you, your heirs, your assigns and your legal representatives hereby forever release, waive, discharge, indemnify, hold harmless and covenant not to sue Massage Therapy Matters Utah, Massage Therapy Matters, LLC and its owners, directors, officers, employees, agents members, managers, instructors and representatives (collectively “Massage Therapy Matters”) from all injuries, damages, losses, expenses, attorneys’ fees, settlements, liabilities, claims, suits and causes of action which may result therefrom, and which may affect Massage Therapy Matters. 4. It is each student’s responsibility to monitor their own activity to may result therefrom, and which may affect Massage Therapy Matters. 4. It is each student’s responsibility
Replace with Match case determine whether it is appropriate for them. Although instructors will provide guidance, each student remains solely responsible for their own safety and well-being. 5. Each instructor reserves the right to refuse participation by any student who behaves in a dangerous, threatening, distressing or disruptive manner with regard to the instructor or any student. 6. If you do not wish to receive physical assistance, you must inform your instructor before each class. I have read the above Disclosure and Release Form, and I fully understand its contents. I voluntarily agree to the terms and conditions stated above.
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How did you hear about Massage Therapy Matters?
(Release to Use Name, Image, Voice, Likeness, and Performance)
I, the undersigned, irreversibly grant to Massage Therapy Matters, LLC, its related entities, and their respective employees, agents, and representatives (collectively called “Massage Therapy Matters”), the full right to create and obtain, in the past, present, and in the future, images, photographs, video, audio, interviews, stories, personal histories, performances (vocal, instrumental, dramatic, or otherwise), mixes, and any other recordings, documents, or materials, in any now known or future media, of my name, image, voice, likeness, performance, and other items (collectively called “Recordings”). I also authorize Massage Therapy Matters to copyright, adapt, edit, translate, summarize, reproduce, perform, display, distribute, publish, license, sublicense, sell, broadcast, post or stream over the Internet, and otherwise use and allow others to use any and all parts of the Recordings, forever and throughout the world, in any and all manners, and in any and all forms of media that Massage Therapy Matters believes suitable.
I agree that I shall have no right, title, or interest in or to the Recordings (or to any work comprising or based on the Recordings, in whole or in part), and that all right, title, and interest in and to the Recordings belongs to Massage Therapy Matters. I waive any and all right to payment or other compensation arising from or related to the Recordings. I will not state or imply, or allow others to state or imply, that Massage Therapy Matters approves of or endorses me or my activities. I further agree to release, defend, and hold Massage Therapy Matters harmless from any claims, damages, or liabilities related to the Recordings or Massage Therapy Matters’s use thereof. I understand this Release is governed by the laws of the State of Utah, U.S.A.
By signing below, I represent that I have read this Release, understand its contents, and agree to this Release.
Name Address Date
Parent/Guardian Consent (If anyone listed above is a minor, that person’s parent/guardian must sign below.)
I, the undersigned, hereby warrant and represent that I am the parent or legal guardian of the minor child named above and printed next to my name below (the “Youth”), that I have full authority to execute this Release on behalf of the Youth, that I have read this Release, and that by signing below I have granted this Release on behalf of the Youth. I hereby agree that I, the Youth, and all other parents or legal guardians, if any, will be bound by all releases, consents, and covenants contained in this Release. I further agree to indemnify and defend Massage Therapy Matters against any and all liabilities relating to the Youth’s actions in connection with the Recordings or Massage Therapy Matters use thereof.
The Massage Therapy Matters season is from September through the end of May. Registration fees are charged annually. Your account will be charged monthly for the classes in which your dancer is enrolled unless paid in full in advance. Dancers will have one opportunity to cancel enrollments mid-season at the end of December for a $25 fee. Otherwise dancers are expected commit to a full season of classes, recitals and performances.