Assumption of Risk, Waiver and Release of Liability, Participation, and Indemnification Agreement

Effective date: 12/01/2020

PROGRAM:   Lifestyle Empowerment for Alzheimer’s Prevention (LEAP!)

DESCRIPTION: Multi-week online program or individual education sessions providing basic exercise and lifestyle tips for Alzheimer’s Disease risk reduction. 

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IN CONSIDERATION FOR THE OPPORTUNITY TO PARTICIPATE IN THE ABOVE-REFERENCED PROGRAM, I FREELY AGREE TO THE FOLLOWING for myself and on behalf of my spouse, children, heirs, parents, guardians, next of kin, legal and personal representatives, executors, administrators, successors, and assigns (collectively, “I” or “my”):

• Medical and health information is given from time to time in the Program. I understand that this information is being given in a public venue for general knowledge and is not intended to replace a personal consultation with my doctor or health care provider, even if the person providing the information at the event is a health care provider (or my health care provider). I will consult with my doctor or health care provider at a scheduled office appointment as to any personal health concerns.
• I understand that low to moderate-intensity exercises may be recommended during this program and there are risks involved when performing exercise. I hereby accept responsibility for my own conduct and actions while participating in any and all exercise. I accept that all exercises may not be appropriate for me and that modifications may be needed for all ability levels. I understand that it is my responsibility to perform the most appropriate version of each exercise for my physical ability.
• I understand and agree that the Program may collect and store the following information on each participant of the Program to assess the impact of the program such as
  • Basic demographics such as age, gender and ethnicity
  • Height and weight
  • Assessment of physical activity, diet, physical function, lifestyle habits
  • Surveys of health goals, health habits, personal history, and program satisfaction
• I agree that this information may be used for future research and marketing purposes. Any research purpose will be reviewed and approved as required by applicable law.  I understand that the confidentiality of the information will be protected. If my information is used for research purposes, absolute confidentiality cannot be guaranteed because persons outside the study team may need to look at the study records. Researchers may publish the results of the study.  If they do, they will only discuss group results.  My name will not be used in any publication or presentation about the study. If used in research, my information will be stored in a manner that does not identify me, so that my information cannot be removed once it is collected.
• I willingly, expressly, and unconditionally assume all risks and dangers associated with my participation in the Program, whether known or unknown, seen or unforeseen, directly related to the Program, incidental to it, or associated with it. I understand that there is no guarantee to my safety while participating in the Program. I fully realize and accept that as a result of my participation in the Program, I may sustain severe and permanent physical or mental injury or death, property damage, financial loss, or other injuries. I understand and accept that the physical risks of participation in the Program include, but are not limited to, acute injuries associated with exercise, such as cardiac events, stroke, and pulmonary events; musculoskeletal injuries from falls or contact with other participants including muscle/ligament tears, sprains, strains, fractures, and dislocations; light-headedness, nausea, fainting, dehydration, and heat exhaustion due to physical exertion; and injuries from slipping or tripping.
• I hereby release, waive any claims against, and agree to hold harmless and to indemnify the following parties with respect to any liability, claims, demands, causes of action, damages, losses, or expenses (including court costs and attorneys’ fees) of any kind or nature arising out of, or in connection with, my participation in the Program or this agreement, and I covenant not to sue them: the State of Kansas, the Kansas Board of Regents, the University of Kansas, the University of Kansas Medical Center, any corporations or entities affiliated with the foregoing, and all employees, officers, agents, representatives, and volunteers of the foregoing (together, the “Released Parties”).

By participating in this Program, I acknowledge that I have read this agreement, and I understand and agree to all of its contents.