GoodLife Participant Form

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Full Name*

Date of Birth*

Your Email*

Address*

City*

State*

Zip Code*

What is the best number to reach you at?*

Secondary Phone Number*

Allergies*

Medical Conditions*

Physician's Restrictions*

Are you a veteran?*

Please tell us how you heard about us?*

Emergency Contact Information

Emergency Contact Name*

Relation*

Emergency Contact Number*

Release: I understand and agree that the information contained on this form may be released for statistical purposes, and I agree to the release of information for that limited purpose only. I understand that any release of information in identifiable form must be accompanied by a signed consent form and that the information will not be used as an eligibility determination or affect participation as a recipient unless a law has specifically restricted program participation. I understand that GoodLife Programs and Activities does not/will not sell any participant information to anyone.

Waiver & Release of Liability: I understand that participating in any program offered by GoodLife Programs & Activities including but not limited to sports, exercise, wellness, health, entertainment, social or travel programs may involve inherent risks and dangers. I also understand that even when reasonable precaution is taken, risk remains inherent and accidents and/or injury can still occur. I acknowledge that I am a willing and voluntary participant in such activities, that I am aware of these risks and accept all responsibility for any damages or personal injury that may occur as a result of my participation.

I declare myself to be physically sound and suffering from no condition, impairment, disease or other illness that would prevent my participation in any programs at GoodLife Programs & Activities. I acknowledge that it is my responsibility to monitor my own condition and share pertinent medical information with the staff, should it present an impediment to safe participation in my selected Center activities. Furthermore, I agree should that be the case, that I will cease participation in such activities until such time as I secure and present a signed authorization form from my physician. In addition, the novel coronavirus known as COVID-19 is an extremely contagious virus that spreads easily through person-to-person contact. The risks of COVID-19 are described in information provided by the New Hampshire Department of Health and Human Services, at https://www.nh.gov/covid19, and the United States Centers for Disease Control and Prevention, at https://www.cdc.gov/coronavirus/2019-ncov, and include severe illness, personal injury, permanent disability, and death. The risk of transmission of and infection from the Covid-19 virus is inherently higher in any area where people congregate or share facilities, and cannot be prevented. GoodLife Programs & Activities may establish rules and procedures to reduce that risk, which, by signing this Acknowledgment and Release, the undersigned agrees strictly to follow, but GoodLife cannot and does not warrant or guaranty the safety of the undersigned when using GoodLife’s facilities or programs.

Release, Waiver, and Covenant Not to Sue The undersigned releases and waives any claims or actions against GoodLife, and its officers, directors, employees, and volunteers, (the “Released Parties”) from any causes of action, claims, or demands of any nature whatsoever, including, but in no way limited to, claims of negligence, which she/he, or her/his successors, may have, now or in the future, against any of the Released Parties on account of personal injury, property damage, death, or accident of any kind, arising out of or in any way related to the use of the GoodLife’s facilities or equipment or participation GoodLife’s programs, whether that participation is supervised or unsupervised, however the injury or damage occurs, and including without limitation any illness or harm caused by or related to the COVID-19 virus.

The undersigned further acknowledges and certifies that (i) she/he is legally competent to sign and deliver this agreement; (ii) the terms of this agreement are legally binding; and (iii) she/he is signing this agreement, after having carefully read it.

I do hereby waive and release any and all rights and claims against The GoodLife Programs & Activities, Inc., its employees, agents, volunteers, instructors and independent contractors from any and all liability for personal injuries or property damage resulting from my use of GoodLife Programs & Activities’ facilities, participation in travel program and/or programming by my voluntary participation.

I have read this entire document, understand it completely and agree to the above.*