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Sign In
My Account
Home
Services
Acupuncture + Chinese Medicine
Functional Diagnostic Nutrition®
Facial Acupuncture + Microneedling
Functional Health for PANDAS
Bodywork + Massage
Chiropractic Care
Personal Training
Energy Work
SHOP
Shop ALL
Holistic Gifts
Wellness Products
Supplements
Hemp Products
GIft Cards
Recommended Products
About
Who we Are
Connect
Press
Blog
Schedule
TO BE ADDED
Birthday Party Intake Form
Kids Mindfulness Classes
Birthday Party
D E T A I L
Name
*
First Name
Last Name
Contact Phone
*
(###)
###
####
Birthday Child's Name + Age
*
Address of Party
*
# of Kids
*
Specific Requests - Games & Sports
*
Rain Date Request
CREDIT CARD INFORMATION
This is to hold the date and will not be charged until the day of.
Credit Card Number
*
Expiration Month
*
Expiration Year
*
CVC Code
*
Billing Zip Code
*
GENERAL LIABILITY + COVID LIABILITY WAIVER
*
PLEASE READ CAREFULLY BEFORE SIGNING. THIS IS A RELEASE OF LIABILITY AND WAIVER OF RIGHTS. By signing in the space provided below, I expressly agree to the following: COVID-19 LIABILITY 1. I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing. 2. I further acknowledge that The NY Well Center LLC has put in place preventative measures both ON PREMISES and OFF PREMISES to reduce the spread of the Coronavirus/COVID-19. I further acknowledge that The NY Well Center LLC can not guarantee that I will not become infected with the Coronavirus/COVID-19 even if The NY Well Center LLC uses reasonable care and takes reasonable steps to attempt to prevent the spread of the virus. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, staff, and other clients and their families. 3. I voluntarily seek services provided by The NY Well Center LLC and acknowledge that I am increasing my risk of exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment. 4. I understand that due to the frequency of visits of other clients, the characteristics of COVID-19, and the inherent nature of receiving services in an indoor space, that I have an elevated risk of contracting the virus simply by being in The NY Well Center LLC. 5. I understand that the risk of becoming exposed to or infected by COVID-19 may result in personal injury, illness, permanent disability, or death. 6. I attest that: * I am not experiencing any symptoms of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell. * I have not traveled internationally within the last 14 days. * I have not traveled to a highly impacted area within the United States of America in the last 14 days. * I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19. * I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non-contagious by state or local public health authorities. * I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19. 7. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury (including but not limited to personal injury, disability and death) to me or anyone else I come into contact with in connection with my receipt of services from The NY Well Center LLC and/or my presence in the premises occupied by The NY Well Center LLC. I hereby release and agree to hold The NY Well Center LLC harmless from and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the center, or that may otherwise arise in any way in connection with any services received from The NY Well Center LLC. I understand that this release discharges The NY Well Center LLC from any liability or claim that I, my heirs, or any personal representatives may have against the salon with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from The NY Well Center LLC. This liability waiver and release extends to the center together with all owners, partners, and employees. GENERAL LIABILITY 1. I hereby acknowledge and agree that The NY Well Center, LLC, a Delaware limited liability company (hereinafter the “Center”) offers a variety of classes and treatments for use by members and guests solely at their own risk. I understand and acknowledge that the Center makes no claims as to the safety, results or the appropriateness of any program, activity, facilities, service, class and/or treatment (collectively, hereafter the “Services”) for any particular individual. Furthermore, I understand that the Center reserves the right to exclude any person from utilizing the Center facilities and/or participating in any Services for any reason whatsoever. 2. I further acknowledge and agree that use of Center facilities and participation in the Services may involve a high degree of risk and at times may be hazardous to my health. I expressly agree to assume all risk associated therewith and agree to forever waive any and all claims and legal rights which I may have whatsoever, to the extent permitted by law, in connection with my use of the Center facilities and Services. 3. I understand that before participating in any Service that I should consult my physician and, in the event my health condition changes while I am using the Center facilities/treatments, I agree to consult with my physician prior to resuming any and all Services at the Center. I understand and agree that all suggestions and/or instruction made by Center staff concerning the Services, exercise, health and nutrition are neither diagnostic, medical advice nor prescriptive and that I should verify the same with my physician, and I will evaluate such instructions and/or suggestions independently and not do anything in contravention of my physician’s orders. Notwithstanding the foregoing, I warrant and represent that I am in good health and that I am able to use the Center facilities and participate in the Services, without limitation. 4. In consideration of using the Center facilities and/or taking part in any Services, I agree, to the fullest extent permitted by law, to forever release, indemnify, defend and hold harmless the Center, its subsidiaries and affiliates, their respective against, officers, directors, owners, contractors and employees (collectively the “Released Parties”) from any and all claims and causes of action which I (or the below-mentioned minor) might otherwise have or be entitled to assert as a result of or related to any physical or mental injury or otherwise, including without limitation death or property damage or loss sustained in connection with my use (or the below-mentioned minor's use) of the Center facilities or participation in any Service, including, without limitation, claims and causes of action based on negligence, breach of warranty or breach of contract. I also agree to indemnify, defend and hold harmless the Released Parties from any and all claims brought by third parties arising out of my (or the below-mentioned minor’s) acts, errors or omissions. 5. I hereby authorize Center personnel or contractors to call for medical assistance for me or the below-mentioned minor and to transport the same to a medical facility or hospital in the event of an emergency. I further agree to be responsible for all costs and expenses associated with any such medical care and/or related transport and I hereby indemnify and hold harmless the Released Parties of and from any such costs. 6. Photo Release: I agree to grant to the Center and its authorized representatives permission to record on photography, film and/or video, pictures of my (or my minors') participation in special events and classes. NO PHOTOGRAPHY, FILM, AND/OR VIDEO WILL EVER BE TAKEN IN PRIVATE ROOMS AND/OR TREATMENTS. I further agree that any or all of the material photographed may be used, in any form, as part of any future publications, brochure, or other printed materials used to promote the Center, and further that such use shall be without payment of fees, royalties, special credit or other compensation. No 7. I agree to abide by all rules and regulations as may be established from time to time by the Center. 8. If I am executing this Release of Liability and Waiver of Rights on behalf of a minor (at least 13 years of age), I warrant and represent that I am the minor's parent or legal guardian. 9.. This Agreement shall be binding on my (or the below-mentioned minor's) estate, heirs, administrators and assigns.
I have read and agree to the terms above regarding the risks of COVID-19.
I have read and agree to the general liability terms above.
Thank you so much! We will contact you if we have any more questions.