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52.44.117.60  Public Scan

URL: https://fs17.formsite.com/ywwHrw/t5yglhjzdx/index.html
Submission: On June 08 via manual from US — Scanned from DE

Form analysis 1 forms found in the DOM

POST https://fs17.formsite.com/res/submit

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        <h1 style="font-weight:bold;font-size:20px;padding:50px 1em ;background-color:rgba(0, 0, 0, 0.38)">TITLE Boxing Club Evanston COVID-19 Liability Waiver</h1>
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      <span class="question top_question">How often would you like to come to class?&nbsp;<b class="icon_required" style="color:#F00">*</b></span>
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        <h1 style="font-size:24px;padding:20px 1em ;">Credit Card Information (Complete Your Cashless Profile With Us)</h1>
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        <div>We ask for a credit card to complete your profile.&nbsp; We do not accept cash at TITLE Boxing Club Evanston and having a credit card on file makes for ease of any purchases you may need to make in the club - hand wraps, gloves, and even
          memberships!&nbsp;&nbsp;</div>
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      <label class="question top_question" for="RESULT_TextField-37">Please confirm the card associated with your account billing:&nbsp;<b class="icon_required" style="color:#F00">*</b>&nbsp;<span class="instructions">🛈</span></label>
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    <div class="clear"></div>
    <div id="q61" class="q full_width display_hidden">
      <a class="item_anchor" name="ItemAnchor41"></a>
      <div class="full_width_space">
        <div>
          <p><strong>GUEST ASSUMPTION OF RISK, CONSENT, RELEASE AND WAIVER</strong></p>
          <p>Boxing and kickboxing courses offered by <strong>WLBM III, Inc</strong>., an independently owned and operated franchisee of TBC International, LLC, and its owners, employees, and instructors (collectively “Fitness Center”) could involve
            physical contact with other individuals and/or heavy bags, which may result in personal injury. Other programs offered by the Fitness Center, including weight lifting, aerobics and other events also present a risk in personal injury to
            the participant (you). In consideration of mutual agreements by which I will use the premises of<strong> WLBM III, Inc</strong> DBA TITLE BOXING CLUB®, which I acknowledge to be beneficial to me, I acknowledge and agree to the following:
          </p>
          <p>I warrant and represent that I am in appropriate physical condition for the physical activities in which I will participate and that such physical activities, even noncontact activities, carry a risk of serious physical injury including
            substantial and permanent injuries, and/or death, and I knowingly and voluntarily assume those risks and waive in advance any claim of liability resulting from those risks. On my own behalf and on behalf of my representatives, my estate,
            and all persons claiming&nbsp; through me directly or derivatively, I hereby agree to hold harmless, release, and discharge in advance <strong>WLBM III, Inc</strong> its franchisor TBC International, LLC and all other TBC International
            LLC franchisees and their respective owners, officers, employees,&nbsp; affiliate companies, and all other participants and nonparticipants associated with those identified entities (hereinafter&nbsp; the "Clubs")&nbsp; from any injury
            that I may receive whether or not from the negligent or intentional&nbsp; acts of those persons released.&nbsp; Furthermore, I agree on my own behalf and behalf of my representatives, estate, successors and assigns to defend the Clubs
            from and against any and all claims and liability that may arise by reason of any injury or death I may sustain from participation in physical activities at the facilities of the TITLE Boxing Club operated by the Clubs, whether caused by
            an intentional act, or by negligence, or otherwise without limitation.&nbsp; This agreement to defend includes any claim, action or liability whatsoever, regardless of whether the claim is made, without limitation, by me, by someone on my
            behalf or by someone whose claim is derived from my injury or death. I acknowledge and agree (1) that it is my responsibility to cover any medical bills that I may incur and to cover myself with any medical insurance I may deem
            appropriate and (2) that I will not and cannot make any claim for medical coverage resulting from any injury or death incurred by me at the facilities of the TITLE Boxing Club owned and operated by the Clubs. The Clubs shall not be liable
            for any loss or theft of my personal property.&nbsp; I also specifically agree that the Clubs shall not be responsible for all such personal or property injuries, damages, loss or theft, even in the event of negligence, fault or failure
            to use due care on the part of the Clubs, and whether such negligence, fault, or failure to use due care is present at the signing of this Agreement or takes place in the future.&nbsp; I hereby consent to the Clubs taking photographs or
            video images of me while in classes or otherwise in the public premises of the Clubs and hereby irrevocably grant the Clubs the right to use my image or likeness in such images or photographs in any advertising, promotion, marketing
            materials including any and all social media, print media, or on the Club’s website.</p>
        </div>
      </div>
    </div>
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          <p><strong>ASSUMPTION OF RISK AND RELEASE OF LIABILITY RELATING TO CORONAVIRUS / COVID-19 (this “Agreement”)</strong></p>
          <p>Coronavirus (COVID-19) has been declared a worldwide pandemic by the World Health Organization.&nbsp; Coronavirus is extremely contagious and is believed to spread mainly from person-to-person contact.&nbsp; As a result, federal, state
            and local governments and federal and state health agencies recommend physical distancing and have, in many places, prohibited the assembly of large groups (usually of 10 or more).&nbsp;</p>
          <p>&nbsp;</p>
          <p>You acknowledge that WLBM III, Inc d/b/a TITLE Boxing Club Evanston has put in place certain “coronavirus rules,” and taken certain preventative measures, to reduce the spread of coronavirus within the facility; however, WLBM III, Inc
            cannot guarantee that you, your guests or your family will not be exposed to or become infected with coronavirus.&nbsp; You understand that by accessing the club, you may be putting yourself, your guests and/or your family at increased
            risk for contracting coronavirus.&nbsp; You further acknowledge that individuals with health conditions such as heart disease, cancer or diabetes may be more likely to suffer more severe symptoms as a result of contracting the
            coronavirus.</p>
          <p>&nbsp;</p>
          <p><em>By signing below, you (referred to below as “I”) understand, acknowledge and agree to the following statements:</em></p>
          <p>&nbsp;</p>
          <ul>
            <li>I assume the risk that I, my guests and/or my child(ren) may be exposed to or become infected with coronavirus and the such exposure and/or infection may result in personal injury, an illness, causing mild symptoms such as fever or
              body aches, or more severe complications, such as pneumonia or organ failure; permanent disability or death; and</li>
          </ul>
          <p>&nbsp;</p>
          <ul>
            <li>I understand that the risk of exposure to or infection with coronavirus may result from the acts, omissions, or negligence or myself or others, including but not limited to, the employees, owners and other members of WLBM III, Inc;
              and</li>
          </ul>
          <p>&nbsp;</p>
          <ul>
            <li>I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself, my guests or my family (including, but not limited to, personal injury, disability or death), illness, damage, loss,
              claim, liability or expense (including medical bills, attorneys’ fees and court costs), or any kind, that I, my guests or my family may experience or incur in connection with my access to the studio or participation in the services
              provided by WLBM III, Inc (collectively, “Claims”); and</li>
          </ul>
          <div>&nbsp;</div>
          <ul>
            <li>I understand that if I do not abide by the safety procedures and protocols set forth by the club, WLBM III, Inc and the guidance of the state of Illinois, I may be denied entry or refused service and WLBM III, Inc may terminate my
              contract, with the remaining balance due at the time of termination; and</li>
          </ul>
          <p>&nbsp;</p>
          <ul>
            <li>
              <strong><u>I hereby release, covenant not to sue, discharge and hold harmless WLBM III, Inc, its franchisor, and each’s employees, agents, owners, representatives, and affiliates (collectively “Releasees”), of and from all Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or related to my access to the studio or participation in the services provided by WLBM III, Inc, whether arising out of the negligent or grossly negligent acts or omissions of any Releasee or otherwise, and whether any coronavirus infection or exposure occurs before, during or after access to the studio or participation in any of the services provided by WLBM III, Inc</u></strong>;
              and</li>
          </ul>
          <p>&nbsp;</p>
          <ul>
            <li>I understand that by signing this release, I am waiving any and all Claims, including those Claims that may be unknown to me, or which I do not suspect to exist at this time. IF I AM A RESIDENT OF CALIFORNIA, I HEREBY EXPRESSLY WAIVE
              ALL RIGHTS, BENEFITS, AND PROTECTIONS I MAY HAVE UNDER CALIFORNIA CIVIL CODE SECTION 1542, WHICH READS AS FOLLOWS:</li>
          </ul>
          <p><strong>&nbsp;</strong></p>
          <p><strong>A general release does not extend to claims that the creditor or releasing party does not know or suspect to exist in his or her favor at the time of executing the release and that, if known by him or her, would have materially
              affected his or her settlement with the debtor or released party.</strong></p>
          <ul>
            <li>I understand and agree that this this Agreement shall be in addition to, and not in lieu of, any other assumption of risk provisions or releases of liability as may be found in my membership agreement, and that such assumption of risk
              and releases of liability provisions remain fully intact.</li>
          </ul>
          <p>&nbsp;</p>
          <ul>
            <li>If any provision of this Agreement is held to be unenforceable, then this Agreement will be deemed amended to the extent necessary to render the otherwise unenforceable provision, and the rest of the Agreement, valid and enforceable.
              If a court or arbiter declines to amend this Agreement as provided herein, the invalidity or unenforceability of any provision of this Agreement shall not affect the validity or enforceability of the remaining provisions, which shall be
              enforced as if the offending provision had not been included in this Agreement. Releasees are third-party beneficiaries to this Agreement and shall have the right to enforce this Agreement as if Releasees were a party hereto.</li>
          </ul>
          <p>&nbsp;</p>
          <ul>
            <li><strong>I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTOOD ALL OF THE TERMS OF THIS AGREEMENT, HAVE BEEN GIVEN THE OPPORTUNITY TO REVIEW ITS TERMS WITH MY LEGAL COUNSEL, AND AM VOLUNTARILY GIVING UP SUBSTANTIAL LEGAL RIGHTS,
                INCLUDING THE RIGHT TO SUE THE COMPANY FOR CLAIMS, WHETHER KNOWN OR UNKNOWN, ARISING OUT OF THE ACTIVITIES.</strong></li>
          </ul>
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Text Content

subject_line


TITLE BOXING CLUB EVANSTON COVID-19 LIABILITY WAIVER




PARTICIPANT INFORMATION


First Name *
Middle Int
Last Name *

Date of Birth *  +
Are You 18 Years or Older? * Yes No
Pronouns
Phone Number *
Email *
Street Address *
City *
State *
Zip Code *

Are you currently a member or class pack holder at TITLE Boxing Club Evanston? *

Yes No


Do you want to be able to use more than one TITLE location? *

Yes No


Are you one of the following: *

Student Teacher/Educator Healthcare Worker Police/Fire Military None of These


Do you have kids under 18 who you are signing this waiver for? *

Yes No


First & Last Name of minor: *
Date of Birth *  +

First & Last Name of minor:
Date of Birth  +

First & Last Name of minor:
Date of Birth  +



FIRST TIME GUEST


How did you hear about us? *

Do you have any injuries or limitations we should know about? *

Have you ever taken a TITLE Boxing Class before? If so, where? *

What are your fitness goals? *

Do you currently have a typical fitness routine? If yes, what? If no, why? *
How often would you like to come to class? *

1-2 classes per week 3+ classes per week




CREDIT CARD INFORMATION (COMPLETE YOUR CASHLESS PROFILE WITH US)


We ask for a credit card to complete your profile.  We do not accept cash at
TITLE Boxing Club Evanston and having a credit card on file makes for ease of
any purchases you may need to make in the club - hand wraps, gloves, and even
memberships!  

Credit/Debit card required to hold Intro to Boxing & Class reservations: * 🛈

 *
 *
 *

Please confirm the card associated with your account billing: * 🛈

 *
 *
 *


GUEST ASSUMPTION OF RISK, CONSENT, RELEASE AND WAIVER

Boxing and kickboxing courses offered by WLBM III, Inc., an independently owned
and operated franchisee of TBC International, LLC, and its owners, employees,
and instructors (collectively “Fitness Center”) could involve physical contact
with other individuals and/or heavy bags, which may result in personal injury.
Other programs offered by the Fitness Center, including weight lifting, aerobics
and other events also present a risk in personal injury to the participant
(you). In consideration of mutual agreements by which I will use the premises of
WLBM III, Inc DBA TITLE BOXING CLUB®, which I acknowledge to be beneficial to
me, I acknowledge and agree to the following:

I warrant and represent that I am in appropriate physical condition for the
physical activities in which I will participate and that such physical
activities, even noncontact activities, carry a risk of serious physical injury
including substantial and permanent injuries, and/or death, and I knowingly and
voluntarily assume those risks and waive in advance any claim of liability
resulting from those risks. On my own behalf and on behalf of my
representatives, my estate, and all persons claiming  through me directly or
derivatively, I hereby agree to hold harmless, release, and discharge in advance
WLBM III, Inc its franchisor TBC International, LLC and all other TBC
International LLC franchisees and their respective owners, officers, employees, 
affiliate companies, and all other participants and nonparticipants associated
with those identified entities (hereinafter  the "Clubs")  from any injury that
I may receive whether or not from the negligent or intentional  acts of those
persons released.  Furthermore, I agree on my own behalf and behalf of my
representatives, estate, successors and assigns to defend the Clubs from and
against any and all claims and liability that may arise by reason of any injury
or death I may sustain from participation in physical activities at the
facilities of the TITLE Boxing Club operated by the Clubs, whether caused by an
intentional act, or by negligence, or otherwise without limitation.  This
agreement to defend includes any claim, action or liability whatsoever,
regardless of whether the claim is made, without limitation, by me, by someone
on my behalf or by someone whose claim is derived from my injury or death. I
acknowledge and agree (1) that it is my responsibility to cover any medical
bills that I may incur and to cover myself with any medical insurance I may deem
appropriate and (2) that I will not and cannot make any claim for medical
coverage resulting from any injury or death incurred by me at the facilities of
the TITLE Boxing Club owned and operated by the Clubs. The Clubs shall not be
liable for any loss or theft of my personal property.  I also specifically agree
that the Clubs shall not be responsible for all such personal or property
injuries, damages, loss or theft, even in the event of negligence, fault or
failure to use due care on the part of the Clubs, and whether such negligence,
fault, or failure to use due care is present at the signing of this Agreement or
takes place in the future.  I hereby consent to the Clubs taking photographs or
video images of me while in classes or otherwise in the public premises of the
Clubs and hereby irrevocably grant the Clubs the right to use my image or
likeness in such images or photographs in any advertising, promotion, marketing
materials including any and all social media, print media, or on the Club’s
website.


Participant or Parent/Guardian Signature *

clear



EMERGENCY CONTACT INFORMATION


First Name *
Last Name *

Relationship *
Phone Number *



PARENT/GUARDIAN INFORMATION


First Name *
Middle Int
Last Name *
Parent/Guardian Date of Birth *  +

Email *
Phone Number *



COVID-19 SPECIFIC WAIVER



ASSUMPTION OF RISK AND RELEASE OF LIABILITY RELATING TO CORONAVIRUS / COVID-19
(this “Agreement”)

Coronavirus (COVID-19) has been declared a worldwide pandemic by the World
Health Organization.  Coronavirus is extremely contagious and is believed to
spread mainly from person-to-person contact.  As a result, federal, state and
local governments and federal and state health agencies recommend physical
distancing and have, in many places, prohibited the assembly of large groups
(usually of 10 or more). 

 

You acknowledge that WLBM III, Inc d/b/a TITLE Boxing Club Evanston has put in
place certain “coronavirus rules,” and taken certain preventative measures, to
reduce the spread of coronavirus within the facility; however, WLBM III, Inc
cannot guarantee that you, your guests or your family will not be exposed to or
become infected with coronavirus.  You understand that by accessing the club,
you may be putting yourself, your guests and/or your family at increased risk
for contracting coronavirus.  You further acknowledge that individuals with
health conditions such as heart disease, cancer or diabetes may be more likely
to suffer more severe symptoms as a result of contracting the coronavirus.

 

By signing below, you (referred to below as “I”) understand, acknowledge and
agree to the following statements:

 

 * I assume the risk that I, my guests and/or my child(ren) may be exposed to or
   become infected with coronavirus and the such exposure and/or infection may
   result in personal injury, an illness, causing mild symptoms such as fever or
   body aches, or more severe complications, such as pneumonia or organ failure;
   permanent disability or death; and

 

 * I understand that the risk of exposure to or infection with coronavirus may
   result from the acts, omissions, or negligence or myself or others, including
   but not limited to, the employees, owners and other members of WLBM III, Inc;
   and

 

 * I voluntarily agree to assume all of the foregoing risks and accept sole
   responsibility for any injury to myself, my guests or my family (including,
   but not limited to, personal injury, disability or death), illness, damage,
   loss, claim, liability or expense (including medical bills, attorneys’ fees
   and court costs), or any kind, that I, my guests or my family may experience
   or incur in connection with my access to the studio or participation in the
   services provided by WLBM III, Inc (collectively, “Claims”); and

 
 * I understand that if I do not abide by the safety procedures and protocols
   set forth by the club, WLBM III, Inc and the guidance of the state of
   Illinois, I may be denied entry or refused service and WLBM III, Inc may
   terminate my contract, with the remaining balance due at the time of
   termination; and

 

 * I hereby release, covenant not to sue, discharge and hold harmless WLBM III,
   Inc, its franchisor, and each’s employees, agents, owners, representatives,
   and affiliates (collectively “Releasees”), of and from all Claims, including
   all liabilities, claims, actions, damages, costs or expenses of any kind
   arising out of or related to my access to the studio or participation in the
   services provided by WLBM III, Inc, whether arising out of the negligent or
   grossly negligent acts or omissions of any Releasee or otherwise, and whether
   any coronavirus infection or exposure occurs before, during or after access
   to the studio or participation in any of the services provided by WLBM III,
   Inc; and

 

 * I understand that by signing this release, I am waiving any and all Claims,
   including those Claims that may be unknown to me, or which I do not suspect
   to exist at this time. IF I AM A RESIDENT OF CALIFORNIA, I HEREBY EXPRESSLY
   WAIVE ALL RIGHTS, BENEFITS, AND PROTECTIONS I MAY HAVE UNDER CALIFORNIA CIVIL
   CODE SECTION 1542, WHICH READS AS FOLLOWS:

 

A general release does not extend to claims that the creditor or releasing party
does not know or suspect to exist in his or her favor at the time of executing
the release and that, if known by him or her, would have materially affected his
or her settlement with the debtor or released party.

 * I understand and agree that this this Agreement shall be in addition to, and
   not in lieu of, any other assumption of risk provisions or releases of
   liability as may be found in my membership agreement, and that such
   assumption of risk and releases of liability provisions remain fully intact.

 

 * If any provision of this Agreement is held to be unenforceable, then this
   Agreement will be deemed amended to the extent necessary to render the
   otherwise unenforceable provision, and the rest of the Agreement, valid and
   enforceable. If a court or arbiter declines to amend this Agreement as
   provided herein, the invalidity or unenforceability of any provision of this
   Agreement shall not affect the validity or enforceability of the remaining
   provisions, which shall be enforced as if the offending provision had not
   been included in this Agreement. Releasees are third-party beneficiaries to
   this Agreement and shall have the right to enforce this Agreement as if
   Releasees were a party hereto.

 

 * I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTOOD ALL OF THE TERMS OF THIS
   AGREEMENT, HAVE BEEN GIVEN THE OPPORTUNITY TO REVIEW ITS TERMS WITH MY LEGAL
   COUNSEL, AND AM VOLUNTARILY GIVING UP SUBSTANTIAL LEGAL RIGHTS, INCLUDING THE
   RIGHT TO SUE THE COMPANY FOR CLAIMS, WHETHER KNOWN OR UNKNOWN, ARISING OUT OF
   THE ACTIVITIES.


Participant or Parent/Guardian Signature *

clear
Today's date *  +


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