Please complete all areas, read and sign where indicated


RIVER NORTH in Hifi Fitness 820 N. Orleans, Suite 100 Chicago, IL 60610	NORTH in WIN Performance 1660 Old Skokie Road Highland Park, IL 60035	PIM WEST in NetGame 145 Plaza Drive Westmont, IL 60559
PATIENT REGISTRATION FORM

DATE:
MINOR PATIENT NAME: <CHILDFIRSTNAME> <CHILDLASTNAME> DOB: <CHILDBIRTHDAY> MINOR PATIENT AGE: GENDER: Male Female MINOR PATIENT NAME: <CHILDFIRSTNAME> <CHILDLASTNAME> DOB: <CHILDBIRTHDAY> MINOR PATIENT AGE: GENDER: Male Female MINOR PATIENT NAME: <CHILDFIRSTNAME> <CHILDLASTNAME> DOB: <CHILDBIRTHDAY> MINOR PATIENT AGE: GENDER: Male Female MINOR PATIENT NAME: <CHILDFIRSTNAME> <CHILDLASTNAME> DOB: <CHILDBIRTHDAY> MINOR PATIENT AGE: GENDER: Male Female MINOR PATIENT NAME: <CHILDFIRSTNAME> <CHILDLASTNAME> DOB: <CHILDBIRTHDAY> MINOR PATIENT AGE: GENDER: Male Female MINOR PATIENT NAME: <CHILDFIRSTNAME> <CHILDLASTNAME> DOB: <CHILDBIRTHDAY> MINOR PATIENT AGE: GENDER: Male Female MINOR PATIENT NAME: <CHILDFIRSTNAME> <CHILDLASTNAME> DOB: <CHILDBIRTHDAY> MINOR PATIENT AGE: GENDER: Male Female MINOR PATIENT NAME: <CHILDFIRSTNAME> <CHILDLASTNAME> DOB: <CHILDBIRTHDAY> MINOR PATIENT AGE: GENDER: Male Female MINOR PATIENT NAME: <CHILDFIRSTNAME> <CHILDLASTNAME> DOB: <CHILDBIRTHDAY> MINOR PATIENT AGE: GENDER: Male Female MINOR PATIENT NAME: <CHILDFIRSTNAME> <CHILDLASTNAME> DOB: <CHILDBIRTHDAY> MINOR PATIENT AGE: GENDER: Male Female
ADULT PATIENT OR PARENT/GUARDIAN (if minor patient) LEGAL NAME:
Pronouns:
DOB:		AGE:
SEX ASSIGNED AT BIRTH:
GENDER IDENTITY:
SPORT:
SCHOOL/TEAM:
LEVEL:
AGENT: (if applicable)	AGENT PHONE #:

MAILING ADDRESS:

Street:

City:

State:

Zip:

Email:

Primary Phone:

Business:

*Are you a Medicare Beneficiary?
Yes No

EMERGENCY CONTACT INFORMATION:

*Name:

*Relation:

Home phone:

*Cell phone:

*PHYSICIAN CONTACT INFORMATION:
As your treating physical therapists, we are required to notify your primary physician of your start of care.

I do not wish for my physician to be notified (physician contact information not needed)

Or

Please send notification to my physician:
Physician Name and Facility:

Who can we thank for referring you?

RELEASE AND WAIVER OF LIABILITY

I understand that this Release And Waiver Of Liability governs all rights and liabilities relating in any way to the receipt by me from Performance in Motion Rehabilitation, Inc. and/or its agents of Services, as that term is defined below. I have read, understand, and agree to be bound by the terms below.

Definitions

“Services” shall mean any and all manner of goods and services offered by Performance in Motion or any other Released Party to you. These services, which may take the form of training, treatment, consulting, and the like, expressly include but are not limited to: evaluations; rehabilitation; reconditioning; performance planning; performance training (including strength & conditioning training, speed& quickness training, plyometric training, and the like); recovery and regeneration training; sports nutrition consultation; supplement and nutrition provision; any consultation related to any item in this list; injury reduction and treatment; technical and tactical instruction; performance enhancement.

“Training” shall mean any act, omission, or other activity required of you or carried out by you in relation to the Services. This term shall not be limited, in any way, with respect to any location site, or facility at which any activities related to the Services takes place.

“Released Parties” shall mean Robbie Ohashi, Jennifer Ohashi, Jacob Brueck, Jyron Aparri, Colleen Lind, Kiera Leafblad, Performance in Motion, along with, in relation to the previously-listed respective Released Parties, all of their officers, directors, shareholders, insurers, partners, employees, employers, agents, successors, contractors, assigns, affiliates, parent corporations, affiliated corporations, and subsidiary corporations.

Terms and Provisions

The risk of injury from participation in sporting events and other strenuous physical activity, including Training, is significant, including the potential for permanent paralysis, other serious injury, and/or death. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS of participation in Training, including, without limitation, risk arising from or relating in any way to the condition of the facilities, equipment, fields, and surrounding premises, the actions of persons other than myself, my own actions, and travel to and from the Training (including, but not limited to, travel services provided by any Released Party or in any vehicle owned, operated, or associated with any Released Party). I UNDERSTAND THAT THERE LEASED PARTIES MAKE NO WARRANTIES and shall in no event be responsible or liable for the defective or dangerous condition of the facilities, equipment, fields, and surrounding premises, except to the extent such condition(s) result(s) solely from the gross negligence or willful misconduct of a Released Party.

I AGREE THAT THERE LEASED PARTIES SHALL NOT BE LIABLE for any claims, demands, injuries, damages, actions, or causes of action that arise in whole or in part due to the negligence of the Released Parties, or any of them. FURTHERMORE, I FOREVER RELEASE AND DISCHARGE, AND AGREE TO INDEMNIFY AND HOLD HARMLESS, the Released Parties from and in relation to all claims, demands, injuries, damages, actions, or causes of action that arise from or relate in any way to my participation in the Training, other than such claims, demands, etc. that arise solely from the gross negligence or willful misconduct of a Released Party. I FURTHER WARRANT AND CERTIFY that I have no health conditions or defects that would prevent me from participating safely in the Training, that I have taken every reasonable act necessary to make this warranty and certification in relation to such participation, and that I am otherwise sufficiently fit and healthy to so participate.

I WARRANT AND UNDERSTAND that it is my sole and personal responsibility to obtain insurance to compensate for any and all injuries which might arise from my participation in the Training, and furthermore agree to look solely to such insurance to cover losses resulting from any injuries, regardless of fault, and waive all rights of subrogation on behalf of any and all Released Parties which may now or ever exist as a result of such insurance.

I agree that I will be solely responsible for any damage (whether to a person or property) I, my guests, agents or invitees cause, including but not limited to any Performance in Motion equipment or personnel and any hotel property or personnel, and will indemnify Performance in Motion, Inc. in connection with any claims, suits, damages, costs, lawsuits, fines, penalties, liabilities, expenses (including attorneys’ fees and costs) and other obligations directly or indirectly arising out of or related to any act or omission by me, my guests,agents or invitees.

IN ANY EVENT, THE LIABILITY OF A RELEASED PARTY TO ME FOR ANY REASON AND UPON ANY CAUSE OF ACTION SHALL NOT EXCEED THE AMOUNT ACTUALLY PAID BY ME TO PERFORMANCE IN MOTION, INC DURING THE TWELVE MONTHS IMMEDIATELY PRECEDING MY ASSERTION OF SUCH CLAIM. THIS LIMITATION APPLIES TO ALL CAUSES OF ACTION IN THE AGGREGATE, INCLUDING, WITHOUT LIMITATION TO EQUITY, BREACH OF CONTRACT, BREACH OF WARRANTY, NEGLIGENCE, STRICT LIABILITY, MISREPRESENTATIONS, AND OTHER TORTS.

If any paragraph, subparagraph, sentence or clause of this Agreement shall be adjudged illegal, invalid or unenforceable, the balance of the Agreement shall remain in full force and effect. This Agreement shall be construed and interpreted under Illinois law. Any lawsuit or claim arising from or relating in any way to Training, Services, and/or this Agreement shall be brought, if at all, in Cook County, Illinois.

I have read this Agreement, fully understand its terms, understand that I have given up substantial rights by signing it,and sign it freely and voluntarily. I acknowledge that I have received valuable consideration in relation to my execution of this Agreement, which I understand to be a prerequisite to my receipt of Services. Finally, I understand that this Agreement shall be of full force and effect as to any and all Services I receive from the Released Parties, without regard to the date or timing of such service.

Patient or Parent/Legal Guardian Name:

Signature (Guardians signature if minor):

Clear

(draw your signature)

Date:

Informed Consent for Physical Therapy and Wellness Services

Ohashi Performance in Motion Rehabilitation, Ltd., a professional corporation doing business as Performance in Motion (“Practice,” “we,” “us”), provides both traditional physical therapy, which may include but is not limited to: providing performance training, active recovery, examinations, evaluations, assessments, testing, and evidence-based exercises; alleviating impairments; and recommending treatment programs in consultation with other healthcare providers (“Physical Therapy Services”), and wellness services, which may include but are not limited to: providing coaching and well-being consultations and sharing information regarding well-being and fitness for educational purposes (“Wellness Services”) (collectively, “Facility Services”). We believe that Wellness Services can aid therapeutic practices and, as such, please note that while we offer Wellness Services as a part of our services to our clients through our licensed physical therapists, we are not certified coaches. Wellness Services are not Physical Therapy Services or any other licensed activity.

Before we provide Physical Therapy Services to you, the law requires that we obtain your informed consent. We also require your informed consent to receive Wellness Services to ensure we have a mutual understanding of your goals and how we can facilitate those goals. You can only provide us with your informed consent after we have discussed your proposed services, the potential risks of those services, the potential benefits of those services, and information about any possible alternative services. Please tell us immediately if you experience any health changes or feel uncomfortable while participating in Facility Services.

Potential Benefits of Physical Therapy Services

Physical Therapy Services may increase strength, enhance stability, improve mobility, and reduce pain associated with your physical ailments. Participating in physical therapy may improve symptoms affecting your physical well-being. Realizing these benefits may require demonstrable effort on your part and the part of your caregivers and family members, including active participation in physical therapy or wellness treatments, if recommended, to support you through your recovery.

Potential Risks of Physical Therapy Services

Participating in Physical Therapy Services may involve some discomfort, including fatigue and soreness. During your participation in Physical Therapy Services, you may find that you feel worse before you feel better. Recovery and change may be easy and swift at times, but it may also be slow and frustrating. We are here to guide you through the process.

Potential Benefits of Wellness Services

Participating in Wellness Services may improve your overall well-being, increase productivity, and inspire confidence. Any benefits realized through Wellness Services that align with benefits from other interventions, including licensed activities, are coincidental. It will be your decision to determine how to best apply our Wellness Services to your lifestyle and other choices about your health.

Potential Risks of Wellness Services

Participating in Wellness Services may also cause discomfort, and feelings of uncomfortableness, depending on the program. If, at any point during wellness coaching, you feel you have reached a point of exhaustion or would otherwise like to end the program, please communicate those thoughts with your wellness coach. We tailor Wellness Services to benefit you, and your progress is the priority.

Alternatives to Facility Services and Discontinuing Care

At any time during your participation in Physical Therapy Services or Wellness Services, you or your designee have the option to discontinue such services. You may also choose to turn to another healthcare provider to address your ailment(s).

We may terminate Physical Therapy Services or Wellness Services if we determine continued treatment puts you at risk and assumption of such risk is not advisable, if your goals have been met, or if ethical or safety issues arise.

You are not required to answer any question by us that you do not wish to give. Please let us know if you prefer not to answer any questions we have during our intake process. You understand that refusal to participate in any portion of the Facility Services does not automatically affect your eligibility for services; however, it may limit our ability to help you. You acknowledge that any diagnosis rendered or treatment provided by our licensed physical therapists necessarily depends on the information you provide to us. If you withhold information, you, therefore, assume the risk that a diagnosis may not be made or may be made incorrectly. In such a case, your treatment might be less successful than it otherwise would be, or it could be entirely unsuccessful.

Agreements and Acknowledgements

I, the undersigned client, acknowledge that the Practice, through its licensed officers, agents, independent contractors, or employees, will take part in providing Physical Therapy Services and Wellness Services for me. I further acknowledge that the ideas, goals, and treatment methods for my health circumstances have been explained to me. I further acknowledge that, when providing Facility Services, the Practice will use methods that it determines, in its professional opinion, to be in my best interests.

I further acknowledge that my progress will be evaluated periodically when I receive Physical Therapy Services and Wellness Services, which may change my physical therapist’s plans or goals. I understand that my care may be transitioned to another physical therapist at the Practice for any reason, including due to the nature of my symptoms or a goodness of fit determination by the Practice.

I further acknowledge and understand that:

The Facility Services and their risks, benefits, side effects, and alternatives have been explained to me;
The Facility Services may not have the results that I expect, and I have been informed as to other possible services that may provide me a benefit;
I have not been given any guarantees about the results of Facility Services;
I have received a copy of my physical therapist’s contact information, including, where applicable, their name, telephone number, business address, and email address;
I have read this entire document and am bound to its terms;
I have truthfully provided the information requested in this document;
I have been offered and have accepted the Practice’s Notice of Privacy Practices;
I authorize the use of my health information for Practice’s rendering of Physical Therapy Services and Wellness Services;
By signing this document, I authorize the Practice to contact my emergency contact if the Practice deems it appropriate;
The Practice’s physical therapists are appropriately licensed physical therapists and have no other professional licenses; and
The Facility Services are not medical services.

By signing below, I acknowledge that I am competent, understand this document, and have been provided material information regarding the proposed care, treatment, or interventions within the scope of Facility Services. I have been provided with the anticipated risks, benefits, side effects, and alternatives to Facility Services, and I have been offered ample time and opportunity to discuss my concerns. I further acknowledge that all my questions have been answered to my satisfaction.

Thus, I hereby provide my informed consent to receive the Facility Services as described in this document.

This document may be electronically signed. Electronic signatures on this agreement are the same as handwritten signatures for validity, enforceability, and admissibility purposes.

Client Name
Client Signature

Clear

(draw your signature)

Date

BILLING METHOD CONFIRMATION

Performance in Motion (PIM) utilizes a direct pay, “cash-based” billing model and is out-of-network with all private medical insurance companies. Each patient is ultimately responsible for payment of all services received at the time of the visit. If you plan to file claims for your Physical Therapy visits to your insurance, we highly recommend calling to verify your own “Out-of-Network Physical Therapy” benefits prior to the start of care. This will provide you with an idea of the amount of reimbursement you might expect and if any additional information is required prior to receiving services. It is your responsibility as the insured to inform us of any additional requirements (such as pre-authorization) needed prior to receiving services. Following each visit, Performance In Motion will provide you with a detailed “superbill” receipt that contains all the necessary information needed for you to submit claims to your insurance. Please note that we are NOT Medicare providers at this time and no services provided by Performance in Motion should be submitted to Medicare for reimbursement.

By my signature below, I certify that I have read, understand, and agree with the terms of this “Billing Method Confirmation”:

Patient or Parent/Legal Guardian Name:

Signature (Guardians signature if minor):

Clear

(draw your signature)

Date:

PREFERRED PAYMENT OPTION

Payment in full will be required at the time of each visit. Each patient is REQUIRED to have a credit card number on file regardless of method of payment. This card may be used for the following:

Medical- In the event of emergency and medical services.
Balances Due- ANY EXISTING BALANCE THAT HAS NOT BEEN PAID WILL AUTOMATICALLY BE CHARGED TO YOUR CREDIT CARD AFTER EACH MONTH (with a receipt to follow).

*My preferred method of payment is:

Please charge my credit card on file automatically at the time of each visit. Automatic credit card charges will be processed 1-7 days following each visit with receipt to follow via email.

I prefer to pay with cash or check at the time of visit with receipt to follow via email.

Worker's Compensation case

Other:

By my signature below, I certify that I have read, understand, and agree with the terms of this payment and credit card information:

Patient or Parent/Legal Guardian Name:

Signature (Guardians signature if minor):

Clear

(draw your signature)

Date:

CANCELLATION POLICY

At Performance in Motion we are committed to providing the highest quality of personalized patient care through an intimate, low patient volume model. Because of this, we recognize that each patient appointment slot is of the utmost value to both us and our patients. We therefore take patient cancellations very seriously as when a patient cancels without giving enough notice, they prevent another patient from being seen.

Please contact us by phone at (312) 877-5767 or by email at support@teampim.com by 2:00PM on the day prior of your scheduled appointment to notify us of any changes or cancellations. To cancel a Monday appointment, please call our office by 2:00PM on the prior Friday. If prior notification is not given,you will be charged a flat cancellation fee of $150. Please note that this cannot be paid through your private health insurance, Health Savings or Flexible Savings accounts.

I acknowledge that I have received and understand the Cancellation Policy and agree to its terms.

Patient or Parent/Legal Guardian Name:

Signature (Guardians signature if minor):

Clear

(draw your signature)

Date:

Good Faith Estimate of Physical Therapy Services

Physical Therapy – CPT codes

97001	Physical Therapy Evaluation (Worker’s comp/Auto ins)	$265
97002	Physical Therapy Re-evaluation (Worker’s comp/Auto ins)	$210
97161	Physical Therapy Evaluation – Level 1	$265
97162	Physical Therapy Evaluation – Level 2	$265
97163	Physical Therapy Evaluation – Level 3	$265
97164	Physical Therapy Re-evaluation	$210

Therapeutic Procedures

97110	Therapeutic exercise, each 15 min	$52.50
97112	Neuromuscular re-education, each 15 min	$52.50
97113	Aquatic therapy with therapeutic exercise, each 15 min	$52.50
97116	Gait training, each 15 min	$52.50
97140	Manual Therapy, each 15 min	$52.50
97530	Therapeutic activities, each 15 min	$52.50
20560	Needling (1-2 muscles)	$52.50
20561	Needling (3+ muscles)	$52.50

Modalities

97104	Electrical stimulation (attended)	$32
97035	Ultrasound	$32

Typical “Follow-up” Physical Therapy visit would amount to:

60 minutes = 4 x 15 min units = $210
90 minutes = 6 x 15 min units = $315

Please note that exact charges for each “Follow-up” visit may vary depending on individual treatment plans and the services provided. Please inquire with your Physical Therapist for more accurate estimations.

Performance In Motion EIN: 37-1635183; NPI: 1104119684
Effective January 1, 2024

NOTICE OF PRIVACY PRACTICES

This notice describes how Ohashi Performance In Motion Rehabilitation, Ltd. d/b/a Performance in Motion may use and disclose your medical information. It also explains how you can get access to this information. Please review carefully.

Patient Rights – This section explains some of your rights and our related responsibilities

You may:

Obtain a copy of your paper or electronic medical record.
◦ Under most circumstances, we will provide you with a copy or a summary of your health information within 30 days of your request. We may charge a reasonable, cost-based fee.
Request confidential communications from us.
◦ You may ask us to contact you in a specific way (e.g., cell phone only), or to send email to a different address. We will comply with all reasonable requests.
Ask us to correct the information in your medical record.
◦ You may ask us to correct health information in your record that you believe is incorrect or incomplete. If we deny your request, we will provide you a written explanation for that denial within 60 days.
◦ If you pay for our services or a healthcare item in full out-of-pocket, you may ask that we not share that information for the purpose of securing payment or sharing our healthcare operations with your health insurer. We will agree to this request unless a law requires us to share that information.
Ask us to limit what information we use or share.
◦ You may ask us to refrain from using or sharing certain health information for your treatment, in our operations, or to obtain payment for our services. We are not required to comply with your request, and we may decline your request if we reasonably believe that it would affect your care.
Request a copy of this Notice of Privacy Practices.
◦ You may request a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act on your behalf.
◦ If you have given someone your medical power of attorney, or if someone is your legal guardian, that person may exercise your right and make choices about your health information. We will verify that this person has this authority and can act for you before we take any action.
Request a list of those with whom we have shared information about you.
◦ You may request a list (called an accounting) of the times that we have shared your health information for the six years prior to the date of your request. The accounting will include the recipient and reason your information was shared. We will include all disclosures except for those relating to treatment, payment, healthcare operations, and certain other disclosures (e.g., those you asked us to make). We will provide you with one accounting per year at no cost, but we will charge a reasonable, cost-based fee if you request another within 12 months.
File a complaint if you feel your privacy rights are violated.
◦ You may complain to our Privacy Officer, Robbie Ohashi, if you believe we violated your rights. You may also file a complaint by sending a letter to:

▪ U.S. Dept. Of Health and Human Services
Office for Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
• You may also call (877) 696-6675 or visit www.hhs.gov. We will not retaliate against you for filing a complaint.

Patient Choices – You have some choices about how we use or share your information. If you have a clear preference for how we share your information in the situations described below, please discuss that with us so we may respect your wishes.

In these situations, you have a right and a choice to instruct us as to how you would like us to:

Share information with your family or others involved in your care.
Share information as we respond to a disaster relief situation.

In other situations, however, we will never share your information unless you provide us with your written permission:

When we seek to use your information for marketing purposes.
When we seek to sell your information.
When we seek to share any psychotherapy notes or HIV-related information from your record. (Although we do not provide mental healthcare or HIV-related services, such information might be included in records shared from your other providers.)

Uses and Disclosures by our Practice – The most common ways we use or share your health information include when we:

Treat you.
◦ We can use your health information and share it with other professionals who are treating you.
Operate our practice.
◦ We can use and share your health information to run our practice, improve your care, and contact you.
Bill for our services.
◦ We can use and share your health information to bill and obtain payment from health plans or other entities.

The less common ways we use or share your health information include when we:

Report suspected abuse, neglect, or domestic violence.
Assist with public health and safety issues.
Comply with state or federal laws.
Respond to workers’ compensation claims.
Assist with product recalls.
Conduct research.
Respond to court or administrative agency orders or subpoenas.
Report adverse medication reactions.
Prevent or reduce a serious threat to anyone’s health or safety.
Contribute to the public good or assist with public health and research.
Demonstrate to the Department of Health and Human Services that our practice is compliant with federal privacy laws.
Respond to law enforcement requests.
Respond to lawsuits and legal actions.

We must comply with several conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumer/index.html

Our Practice Responsibilities

The law requires us to maintain the privacy and security of your protected health information. We will alert you promptly if a breach occurs that may have compromised the privacy or security of your information. We must comply with the duties and privacy practices described in this notice, and we must offer you a copy of this document. We will not use or share your information, other than as described here, without your express written permission. If you authorize a use or disclosure of your information, you may revoke that authorization in writing at any time.

For more information, visit the HHS website at:

www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html

About this notice

This notice is effective on June 1, 2018
Our Chief Privacy Officer is Robbie Ohashi
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request and on our website.

I acknowledge that I have received and understand both the Consent to Treat and HIPAA Notice of Privacy Practices and agree to their terms.

Signature (Guardians signature if minor)

Clear

(draw your signature)

Date

PATIENT/PHYSICAL THERAPIST COMMUNICATION

While use of email or phone is considered protected communication under HIPAA guidelines, any Personal Health information communicated via “cellphone texting” is not.

In addition, Performance in Motion may offer the use of the TrueCoach software platform to build and communicate your exercise and/or training program with you. Though every effort is made to minimize the amount of your personal health information on this platform, it is not protected under HIPAA guidelines.

By my signature below, I certify my understanding that any personal health information communicated via text, either to or from my Physical Therapist, and on the TrueCoach platform will not be protected under HIPAA guidelines:

Signature (Guardians signature if minor)

Clear

(draw your signature)

Date:

MEDICAL SYSTEMS REVIEW

Date:
Adult Patient or Parent/Guardian (if Minor Patient) Name:
Age: Date of Birth:
Minor Patient Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Age: Date of Birth:* <CHILDBIRTHDAY> Minor Patient Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Age: Date of Birth:* <CHILDBIRTHDAY> Minor Patient Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Age: Date of Birth:* <CHILDBIRTHDAY> Minor Patient Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Age: Date of Birth:* <CHILDBIRTHDAY> Minor Patient Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Age: Date of Birth:* <CHILDBIRTHDAY> Minor Patient Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Age: Date of Birth:* <CHILDBIRTHDAY> Minor Patient Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Age: Date of Birth:* <CHILDBIRTHDAY> Minor Patient Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Age: Date of Birth:* <CHILDBIRTHDAY> Minor Patient Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Age: Date of Birth:* <CHILDBIRTHDAY> Minor Patient Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Age: Date of Birth:* <CHILDBIRTHDAY>
Date of last Physical:

Please fill out the following health information honestly and thoroughly, to the best of your knowledge. Do you now, or have you in the past, had any of the following (please consider during and/or after exercise):

NONE OF THE BELOW APPLY TO ME

Anemia

AIDS/HIV

Allergies

Anorexia/Bulimia

Arthritis

Asthma

Blood Disorder

Blood Transfusion

Cancer

Chest Pain/Angina

Cholesterol Elevation

Chronic Bronchitis

Bowel/Bladder Dysfunction

Concussion

Deafness/Hearing Problems

Diabetes

Digestive Problems

Dizziness/Fainting

Seizures

Fatigue

Fractures

Gallbladder Problems

Gall Stones

Glaucoma

Hay Fever

Headaches

Heart Attack

Heart Disease

Heart Murmur

Heart Palpitations

Heart Related Illness

Hepatitis

Hernia

High Blood Pressure

Hypoglycemia

Kidney/Bladder Infections

Kidney Stones

Kidney Disease

Liver Disease

Menstrual Irregularities

Metal Implants

Migraines

Mononucleosis

Muscle/Joint Injury

Nausea/Vomiting

Neurological Disorders

Numbness/Tingling

Osteoarthritis

Osteoporosis

Pacemaker

Prostate Problems

Phlebitis

Rectal Problems

Respiratory Problems

Rheumatic Fever

Rheumatoid Arthritis

Ringing in your Ears

Sickle Cell Disease

Skin Abnormalities

Smoking

Stroke

Surgeries

Thyroid Condition

Tuberculosis

Ulcers

Vision Problems

Viral Infection

If you have checked any of the above, or have any other health issues that have affected you in the past, or are currently affecting you, that were not listed above, please explain:

Have you ever had a surgery?
Yes (describe on “Injury History” form)
No

Have any relatives or family members died from heart problems and/or sudden death before the age of 35?
Yes No

Has a physician ever denied or restricted your participation in sports due to heart problems?
Yes No

Have you ever been advised by a physician to limit your activity in sports or physical activity?
Yes No

Have you ever had an EKG of your heart performed?
Yes (please list date, abnormal findings)
No

Do you have only one of two paired functioning organs (eyes, kidneys, ovaries, etc.)?
Yes (please list date, abnormal findings)
No

Do you have any allergies (including but not limited to meds, supplements, food, stings/insect bites, etc.)
Yes (please list date, abnormal findings)
No

Please list any medication(s)you are currently taking and for what condition(s):

Please list any supplements or vitamins you are currently taking?

Have you gained OR lost a significant amount of weight in the last year
Yes (please list date, abnormal findings)
No

Is there any reason(s) why you should not participate in physical training at Performance in Motion?
Yes (please list date, abnormal findings)
No

INJURY HISTORY
On the diagram above, please indicate the regions where your symptoms occur:

LOCATION 1:

Injury Type:

Date of Onset:
Treatment:

Current Status:

LOCATION 2:

Injury Type:

Date of Onset:
Treatment:

Current Status:

LOCATION 3:

Injury Type:

Date of Onset:
Treatment:

Current Status:

LOCATION 4:

Injury Type:

Date of Onset:
Treatment:

Current Status:

LOCATION 5:

Injury Type:

Date of Onset:
Treatment:

Current Status:

LOCATION 6:

Injury Type:

Date of Onset:
Treatment:

Current Status:

The statements on all three medical history forms are true and complete to the best of my knowledge.

DISABILITIES OF THE ARM, SHOULDER, AND HAND SCORE

Patient or Parent/Guardian Name:

Minor Patient Name: <CHILDFIRSTNAME> <CHILDLASTNAME>

Date:

Please rate your ability to do the following activities in the last week by choosing the number below the appropriate response.

ACTIVITIES	No Difficulty	Mild Difficulty	Moderate Difficulty	Severe Difficulty	Unable
1. Open a tight or new jar	1	2	3	4	5
2. Write	1	2	3	4	5
3. Turn a key	1	2	3	4	5
4. Prepare a meal	1	2	3	4	5
5. Push open a heavy door	1	2	3	4	5
6. Place an object on a shelf above your head	1	2	3	4	5
7. Do heavy household chores (e.g. wash walls or floors)	1	2	3	4	5
8. Garden or do yard work	1	2	3	4	5
9. Make a bed	1	2	3	4	5
10. Carry a shopping bag or briefcase	1	2	3	4	5
11. Carry a heavy object (over 10 lbs.)	1	2	3	4	5
12. Change a lightbulb overhead	1	2	3	4	5
13. Wash or blow dry your hair	1	2	3	4	5
14. Wash your back	1	2	3	4	5
15. Put on a pullover sweater	1	2	3	4	5
16. Use a knife to cut food	1	2	3	4	5
17. Recreational activities which require little effort (e.g. card playing, knitting)	1	2	3	4	5
18. Recreational activities in which you take some force or impact through your arm, shoulder or hand (e.g. golf, hammering, tennis)	1	2	3	4	5
19. Recreational activities in which you move your arm freely (e.g. playing Frisbee, badminton)	1	2	3	4	5
20. Manage transportation needs (getting from one place to another)	1	2	3	4	5
21. Sexual activities	1	2	3	4	5
TOTAL

DISABILITIES OF THE ARM, SHOULDER, AND HAND

Questions	Not at all	Slightly	Moderately	Quite a bit	Extremely
22. During the past week, to what extent has your arm, shoulder or hand problem interfered with your normal social activities with family, friends, neighbors or groups?	1	2	3	4	5
23. During the past week, were you limited in your or other regular activities as a result of your arm, shoulder, or hand problem?	1	2	3	4	5

Please rate the severity of the following symptoms in the last week.

	None	Mild	Moderate	Severe	Extreme
24. Arm, shoulder or hand pain.	1	2	3	4	5
25. Arm, shoulder or hand pain when you performed any specific activity.	1	2	3	4	5
26. Tingling (pins and needles) in your arm, shoulder or hand.	1	2	3	4	5
27. Weakness in your arm, shoulder or hand.	1	2	3	4	5
28. Stiffness in your arm, shoulder or hand.	1	2	3	4	5

Questions	No Difficulty	Mid Difficulty	Moderate Difficulty	Severe Difficulty	So Much Difficulty I Can't Sleep
29. During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand?	1	2	3	4	5

Questions	Strongly Disagree	Disagree	Neither Agree Nor Disagree	Agree	Strongly Agree
30. I feel less capable, less confident or less useful because of my arm, shoulder or hand problem.	1	2	3	4	5

RAW SCORE = / 150
FORMULA: ([(SUM OF n RESPONSES)/n] - 1)(25) = DASH SCORE (n = number or completed items)
DASH SCORE =

Hudak P, Amadio PC, Bombardier C, and the Upper Extremity Collaborative Group. Development of an Upper Extremity Outcome Measure: The DASH (Disabilities of the Arm, Shoulder, and Hand). American Journal of Industrial Medicine 1996; 29:602-608.

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Our Privacy Policy

PLEASE NOTE THAT WAIVERKING, INC.’S (“WaiverKing”) PRIVACY POLICY HAS CHANGED EFFECTIVE May 25th, 2018.

You acknowledge that this privacy policy is a part of our website’s Terms of Service, and by accessing or using our website, you agree to be bound by all of its terms and conditions. IF YOU DO NOT AGREE TO THESE TERMS, AS UPDATED, PLEASE IMMEDIATELY STOP ACCESSING THE WEBSITE.

This document explains how we use your personal data.

When you sign up to use this service provider’s services, you do so through software provided by us, WaiverKing.

We are committed to ensuring the privacy of all users of our software and services and other visitors to our website. In this policy we explain how we hold, process and retain your personal data.

In respect to the account data, waiver data, and payment data (as defined below) that you provide to us, we are acting as a data processor on behalf of the service provider, who will be acting as the data controller in respect to such data. We will never store or control this data. You should direct any requests or queries you have regarding this data to the data controller, your service provider.

1. How we use your personal data

1.1. This section provides you with information about:

a) what personal data we hold and process;

b) in respect of personal data that we did not collect from you directly, where we obtained that data from, and what types of data we have collected;

c) the purposes for which we may process your personal data; and

d) the legal grounds on which we process your data.

Members and end users of our services

1.2. Account data. We may process information about you that you provide to us when you first sign up with a service provider ("account data"). This account data may include your name, address, telephone number, email address, date of birth, gender, employment details, and a photograph of you. We may use this data to create your account with the service provider when you sign up. This account data may be updated each time you complete a document through our software. We do not process your account data in any other way, or have access to it in any way.

The legal basis for this processing is our legitimate interests in providing our services to our clients, and ensuring that your account is updated each time that you complete a document through our software.

1.3. Waiver data. If you are using our software in order to sign documents such as a waiver, health form, contract, or questionnaire, we may process information that you put into such documents (“waiver data”). This waiver data may include your name, signature, date of birth, email address, information about your health and medical history, and any other information that you are required or requested to put into the document.

Once you have completed the document, we will process it, convert the document into a different format, and send it to your account with the service provider in order for it to be stored. We will never store your data permanently on our systems (although it may be stored in your account with your service provider).

The purpose for our processing your data in this way is to maintain and administer a complete and accurate record of the documents that you have signed and completed for your service provider. The legal basis for our processing your waiver data (to the extent that such waiver data does not class as a special category of personal data), will be our legitimate interests in providing our services to our clients who have asked you to complete the document in question, in order to ensure that a complete and accurate record of your signing and completing the documents is maintained and administered.

1.4. Sensitive Personal Data. During the course of using our software and services and providing us with information in order for us to provide our services to you, you may provide us with sensitive information about yourself (“sensitive data”). This sensitive data may include your health and medical history. We may use this data for providing our services to you. However, we will only process this sensitive data if you consent to us doing so.

[The consent to use this information needs to be provided by the parent for children under the age of 13. Anyone over the age of 13 can provide consent for use of their data under GDPR]

We comply with the requirements of the Children’s Online Privacy Protection Act. You must be at least 18 years old to have our permission to use the WaiverKing website. If you are between the ages of 13 and 17, or under the age of majority where you live, you represent that your legal guardian has reviewed and agreed to this privacy policy.

Other processing that we may carry out

1.5. Website data. We may process data about your use of our website and services ("website data"). The website data may include your IP address, geographical location, browser type and version, operating system, referral source, length of visit, page views and website navigation paths, as well as information about the timing, frequency and pattern of your service use. The source of the website data is our analytics tracking system. This website data may be processed for the purposes of analyzing the use of the website and services.

The legal basis for this processing is our legitimate interests, namely monitoring and improving our website and services.

We may also process this data for the purposes of diagnosing any issues we detect in relation to the use of our products or services. This data may be collected by our error-tracking software which is provided by Rollbar. We always try to ensure that any such data is anonymized so that you cannot be identified before it is stored in our records.

The legal basis for this processing is our legitimate interests in monitoring and improving our products and services.

1.6. Enquiry data. We may process information contained in any enquiry you submit to us regarding our products or services ("enquiry data"). The enquiry data may be processed for the purposes of offering, marketing and selling relevant products and/or services to you.

The legal basis for this processing is our legitimate interests, namely dealing with and responding to your enquiry appropriately.

1.7. Notification data. We may process information that you provide to us for the purpose of subscribing to our blog and press releases ("notification data"). The notification data may be processed for the purposes of sending you newsletters.

Where you are a corporate customer, the legal basis for this processing is our legitimate interests, namely the marketing of relevant products and services to you.

1.8. Correspondence data. We may process information contained in or relating to any communication that you send to us ("correspondence data"). The correspondence data may include the communication content and metadata associated with the communication. Our website will generate the metadata associated with communications made using the website contact forms. The correspondence data may be processed for the purposes of communicating with you and record-keeping.

The legal basis for this processing is our legitimate interests, namely the proper administration of our website and business and communications with users.

1.9. Payment data. We do not process payment information relating to goods and services that you purchase from the service provider. However, we do capture certain data relating to your payments and use them to update your account with the service provider ("payment data"). The payment data may include your contact details, your card details and the transaction details. The payment data may be processed for the purposes of updating your account with the service provider. The legal basis for this processing is our legitimate interests, namely our interest in the proper administration of our software and ensuring your account with the service provider is updated.

1.10. Other processing activities. In addition to the specific purposes for which we may process your personal data set out above, we may also process any of your personal data where such processing is necessary for compliance with a legal obligation to which we are subject, or in order to protect your vital interests or the vital interests of another natural person.

2. Providing your personal data to others

2.1. To our clients and partner service providers. The only third parties that we will disclose your personal data to are our clients (your service provider) who is the data controller in respect to the account data, waiver data, and payment data that we collect about you, and MINDBODY Inc. (“MINDBODY”), who provide software services to service providers in conjunction with the WaiverKing software. Your accounts are created by WaiverKing in the MINDBODY software on behalf of our clients.

2.2. Our insurers/professional advisers. We may disclose your personal data to our insurers, legal counsel, and/or professional advisers insofar as reasonably necessary for the purposes of obtaining and maintaining insurance coverage, managing risks, obtaining professional advice and managing legal disputes.

2.3. Where we provide your personal data to any third party. Where we share your personal data with any of the third parties referred to above, we will ensure this processing is protected by appropriate safeguards including a suitable data processing agreement with that third party.

2.4. To comply with legal obligations. In addition to the specific disclosures of personal data detailed above, we may also disclose your personal data where such disclosure is necessary for compliance with a legal obligation we have to comply with, or in order to protect your vital interests or the vital interests of another individual. This may include disclosing your personal data in response to lawful requests by public authorities, including to meet national security or law enforcement requirements.

2.5. We take reasonable and appropriate steps to ensure that third-party agents and service providers process your personal data in accordance with our Privacy Shield obligations and to stop and remediate any unauthorized processing. Under certain circumstances and pursuant to applicable laws, we may remain liable for the acts of our third-party agents or service providers who perform services on our behalf for their handling of your personal data that we transfer to them.

3. Transfers of your personal data outside of the European Economic Area

As further detailed below, we may transfer your personal data to our servers based in the US, as we are part of the Privacy Shield. Otherwise, where your personal data is transferred outside of the EEA, we will ensure that either (a) The European Commission has made an "adequacy decision" with respect to the data protection laws of the country to which it is transferred, or (b) we have entered into a suitable data processing agreement with the third party situated in that country to ensure the adequate protection of your data. In all cases, transfers outside of the EEA will be protected by appropriate safeguards.

4. Retaining and deleting personal data

4.1. Personal data that we process for any purpose or purposes shall not be kept for longer than is necessary for that purpose or those purposes. Details about members of our clients (your service provider) and end users of our services, including the account data, waiver data and sensitive personal data, will not be stored by WaiverKing.

4.2. Unless we contact you and obtain your consent for us to retain your personal data for a longer period, we will retain and delete your personal data as follows:

a) Website data will be retained for 12 months following the date of our last contact or dealing with you, at the end of which period it will be deleted from our systems.

b) Enquiry data will be retained for 12 months following the date of our last contact or dealing with you, at the end of which period it will be deleted from our systems.

c) Notification data (other than Notification data that is also Contact data) will be retained for 12 months following the date of our last contact or dealing with you, at the end of which period it will be deleted from our systems.

d) Correspondence data will be retained for 12 months following the date of our last contact or dealing with you, at the end of which period it will be deleted from our systems.

4.3. We may retain your personal data where such retention is advisory and/or necessary for compliance with a legal obligation to which we are subject (such as with regard to applicable statutes of limitations, litigation or regulatory investigations), or in order to protect your vital interests or the vital interests of another natural person.

5. Your rights

5.1. You may instruct us to provide you with any personal information we hold about you; provision of such information will be subject to:

a) your request not being found to be unfounded or excessive, in which case a charge may apply; and

b) the supply of appropriate evidence of your identity (for this purpose, we will usually accept a notarized photocopy of your driver’s license and/or passport and an original copy of a utility bill showing your current address).

5.2. We may withhold personal information that you request to the extent permitted by law.

5.3. You may instruct us at any time not to process your personal information for marketing purposes.

5.4. In practice, you will usually expressly agree in advance to our use of your personal information for marketing purposes, or we will provide you with an opportunity to opt out of the use of your personal information for marketing purposes.

5.5. Your right to access your data. You have the right to ask us to confirm whether or not we process your personal data and, to have access to the personal data, and any additional information. That additional information includes the purposes for which we process your data, the categories of personal data we hold and the recipients of that personal data. You may request a copy of your personal data. The first copy will be provided free of charge, but we may charge a reasonable fee for additional copies.

5.6. Your right to correct. If we hold any inaccurate personal data about you, you have the right to have these inaccuracies corrected. Where necessary for the purposes of the processing, you also have the right to have any incomplete personal data about you completed.

5.7. Your right to erasure. In certain circumstances you have the right to have personal data that we hold about you erased. This will be done without undue delay. These circumstances include the following: (1) it is no longer necessary for us to hold those personal data in relation to the purposes for which they were originally collected or otherwise processed; (2) you withdraw your consent to any processing which requires consent; (3) the processing is for direct marketing purposes; and/or (4) the personal data have been unlawfully processed. However, there are certain general exclusions of the right to erasure, including where processing is necessary: for exercising the right of freedom of expression and information; for compliance with a legal obligation; or for establishing, exercising or defending legal claims.

5.8. Your right to restrict processing. In certain circumstances you have the right for the processing of your personal data to be restricted. These circumstances include the following: (1) you do not think that the personal data we hold about you is accurate; (2) your data is being processed unlawfully, but you do not want your data to be erased; (3) it is no longer necessary for us to hold your personal data for the purposes of our processing, but you still require that personal data in relation to a legal claim; and/or (4)you have objected to processing, and are waiting for that objection to be verified. Where processing has been restricted for one of these reasons, we may continue to store your personal data. However, we will only process it for other reasons: with your consent; in relation to a legal claim; for the protection of the rights of another natural or legal person; or for reasons of important public interest.

5.9. Your right to object to processing. You can object to us processing your personal data where our legal basis for the processing is that it is necessary for: the performance of a task carried out in the public interest, or in the exercise of any official authority vested in us; or the purposes of our legitimate interests or those of a third party. If you make an objection, we will stop processing your personal information unless we are able to: demonstrate compelling legitimate grounds for the processing, and that these legitimate grounds override your interests, rights and freedoms; or the processing is in relation to a legal claim.

5.10. Your right to object to direct marketing. You can object to us processing your personal data for direct marketing purposes. If you make an objection, we will stop processing your personal data for this purpose.

5.11. Your right to data portability. Where you have given us consent to process your personal data, or where we are processing your personal data for the performance of a contract, you have a legal right to receive a copy of the personal data we hold about you in a structured, commonly used and computer readable format. When a data request is made of us we will make available all applicable personal data to you in a computer readable format and will transmit your personal data to the appropriate third party pursuant to your instruction. We will not process your data in this way if we believe that it may pose a threat to the security of the data.

5.12. Your right to object for statistical purposes. You can object to us processing your personal data for statistical purposes on grounds relating to your particular situation, unless the processing is necessary for performing a task carried out for reasons of public interest.

5.13. Automated data processing. To the extent that the legal basis we are relying on for processing your personal data is consent, and where the processing is automated, you are entitled to receive your personal data from us in a structured, commonly used and computer-readable format. However, you may not have this right if it would adversely affect the rights and freedoms of others.

5.14. Complaints to a supervisory authority pursuant to the GDPR. If you think that our processing of your personal data infringes data protection laws, you can lodge a complaint with a supervisory authority responsible for data protection. You may do this in the EU member state of your habitual residence, your place of work or the place of the alleged infringement. This provision is only applicable if you are subject to the protections of the GDPR.

5.15. Complaints if you are not subject to the protections of the GDPR. If you think that our processing of your personal data infringes data protection laws you may contact us via email at privacy@waiverking.com or mail at: WaiverKing, Inc. 340 S Lemon Ave # 2018 Walnut, California 91789.

5.16. Right to withdraw consent. To the extent that the legal basis we are relying on for processing your personal data is consent, you are entitled to withdraw that consent at any time. Withdrawal will not affect the lawfulness of processing before the withdrawal.

5.17. Exercising your rights. You may exercise any of your rights in relation to your personal data by written notice to us in addition to the other methods specified above.

5.18. Point of Contact Data. PARAGRAPHS 5.1 – 5.17 SHALL NOT APPLY TO ACCOUNT DATA, WAIVER DATA, OR PAYMENT DATA OBTAINED OR PROCESSED BY WAIVERKING. IN RESPECT OF SUCH DATA:

a) WAIVERKING IS ACTING AS A PROCESSOR OF THAT DATA AND THE MAIN CONTRACTOR IS THE CONTROLLER;

b) YOU SHOULD CONTACT THE SERVICE PROVIDER TO EXERCISE THE RIGHTS SET OUT IN THIS PARAGRAPH 5

6. Links To Other Websites. Except as otherwise discussed in this privacy policy, this document only addresses the use and disclosure of information we collect from you. Other websites accessible through our website have their own privacy policies and data collection, use, and disclosure practices. Please consult each website’s privacy policy. We are not responsible for the policies or practices of third parties, including any third-party site or other products and services used in connection with WaiverKing’s services. The inclusion of a link does not imply endorsement of the linked site or service by us or by our affiliates.

We are not responsible for the collection, usage and disclosure policies and practices (including the data security practices) of other organizations, such as, Apple, Google, Microsoft, or any other operating system provider, wireless service provider or device manufacturer, including any personal data you disclose to other organizations through or in connection with WaiverKing’s services.

7. Security of Your Information. The security of personal data is a high priority at WaiverKing. We seek to use reasonable technical, administrative and physical safeguards to protect personal data within our organization. Unfortunately, no data transmission or storage system can be guaranteed to be 100% secure. As a result, while we strive to protect your personal data, you acknowledge that: (a) there are security and privacy limitations of the Internet which are beyond our control; (b) the security, integrity, and privacy of any and all information and data exchanged between you and us through the website cannot be guaranteed; and (c) any such information and data may be viewed or tampered with in transit by a third party.

8. IP Addresses and Cookies. Cookies are very small text files that are stored on your computer when you visit some websites.

We use cookies to help identify your computer, including where available, your IP address, operating system and browser type, for system administration so we can keep your activity secure, tailor your user experience and remember your preferences. This is statistical data and does not identify any individual. You are always free to decline our cookies if your browser permits, but some parts of our website may not work properly.

9. Your California Privacy Rights: Notice to California Customers and Opt-Out Information. Residents of the State of California, under certain provisions of the California Civil Code, have the right to request from companies conducting business in California a list of all third parties to which the company has disclosed certain personal data, as defined under California law, during the preceding year for third party direct marketing purposes. You are limited to one request per calendar year. In your request, you must supply appropriate evidence of your identity and attest to the fact that you are a California resident and provide a current California address for our response. You may request the information by writing to privacy@waiverking.com

Some web browsers incorporate a “Do Not Track” feature that signals to websites that you visit that you do not want to have your online activity tracked. California residents are entitled to know how WaiverKing, Inc. responds to “Do Not Track” signals. How browsers communicate the Do Not Track signal is not yet uniform, so a standard technological response has not yet been developed by the appropriate technology communities. For this reason, we do not respond to Do Not Track signals currently. To opt out of direct advertising on our website, please send a request to the address above. The effect of an opt-out will be to stop direct advertising, but it will still allow the collection of usage data for certain purposes (e.g., research, analytics, and internal online services operation purposes).

10. Privacy Shield Framework

10.1. WaiverKing Inc. complies with the EU-U.S. and Swiss-U.S. Privacy Shield Framework as set forth by the U.S. Department of Commerce regarding the collection, use, and retention of personal information transferred from the European Union and Switzerland to the United States. WaiverKing has certified to the Department of Commerce that it adheres to the Privacy Shield Principles. If there is any conflict between the terms in this privacy policy and the Privacy Shield Principles, the Privacy Shield Principles shall govern. To learn more about the Privacy Shield program, and to view our certification, please visit https://www.privacyshield.gov/

10.2. In compliance with the Privacy Shield Principles, WaiverKing commits to resolve complaints about our collection or use of your personal information. Any individual(s) with inquiries or complaints regarding our Privacy Shield policy should contact us at: privacy@waiverking.com

10.3. WaiverKing Inc. has further committed to refer unresolved Privacy Shield complaints to Judicial Arbitration and Mediation Services (JAMS), an alternative dispute resolution provider located in the United States. If you do not receive timely acknowledgment of your complaint from us, or if we have not addressed your complaint to your satisfaction, please visit https://www.jamsadr.com/eu-us-privacy-shield for more information or to file a complaint. The services of JAMS are provided at no cost to you. In certain situations, you may also have the right to pursue binding arbitration under the Privacy Shield Framework.

10.4. You may have the option to select binding arbitration for the resolution of your complaint under certain circumstances, provided you have taken the following steps: (1) raised your complaint directly with WaiverKing Inc. and provided us the opportunity to resolve the issue; (2) made use of the independent dispute resolution mechanism identified above; and (3) raised the issue through the relevant data protection authority and allowed the U.S. Department of Commerce an opportunity to resolve the complaint at no cost to you. For more information on binding arbitration, see U.S. Department of Commerce's Privacy Shield Framework: Annex I (Binding Arbitration).

10.5. For purposes of enforcing compliance with the Privacy Shield, WaiverKing is subject to the investigatory and enforcement authority of the U.S. Federal Trade Commission.

10.6. WaiverKing Inc. is controlled and operated by us from the United States. Except where you are a resident of a Member State of the EU, in which case paragraphs 2 and 3 above will apply, your personal data may be stored and processed in any country in which we engage service providers, and by using WaiverKing’s services you understand that your information may be transferred to countries outside of your country of residence, including the United States, which may have data protection rules that are different from those of your country. In certain circumstances, courts, law enforcement agencies, regulatory agencies or security authorities in those other countries may be entitled to access your personal data. Regardless of where your information is processed, we apply the same protections described in this policy.

11. Changes to the privacy policy. We reserve the right to change this policy at any time, without prior notice to you. Such changes, modifications, additions, or deletions shall be effective immediately upon notice thereof, which may be given by means including, but not limited to, issuing an e-mail to the e-mail address provided by you or posting the revised policy on this page. You acknowledge and agree that it is your responsibility to maintain a valid e-mail address and/or review the WaiverKing website and this policy periodically, and be aware of any modifications. Your continued use of the WaiverKing website after such modifications will constitute your: (a) acknowledgment of the modified policy; and (b) agreement to abide and be bound by the modified policy.

12. Our details

12.1. This website and software is owned and operated by WaiverKing Inc.

12.2. We are registered in the state of California under registration number C3518177, and our registered office is at 340 S Lemon Avenue, # 2018 Walnut, California 91789.

12.3. You can contact us:

a) by mail, using the postal address given above;

b) using our website contact form;

c) by telephone, on the contact number published on our website from time to time; or

d) by email, using the email address published on our website from time to time.

13. Data protection officer

Our data protection officer may be contacted via email: privacy@waiverking.com, or telephone: +1 (888) 211-6693.

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