In-order to comply with regulation and for both your safety and our own please be so kind to complete this form prior to EACH AND EVERY VISIT. Failure to do so online will result in backlog at the front desk as we will require this then in hard copy prior to allowing access
I AGREE to notify Wellness In Motion (by email to firstname.lastname@example.org) of any change in status, including diagnosis with Coronavirus and/or quarantine, within thirty (30) days either before or following a visit to the facility.
I WILL, if asked, wear a mask (of the specifications recommended by any WIM staff) at all times while visiting the facility, and will take all reasonable prophylactic steps that may be recommended by WIM, staff and/or any relevant authority.
I WILL consent to having my temperature taken by any representative or agent of the building or staff, during, and after any visit, and will provide any follow up information reasonably requested by WIM.
I ACKNOWLEDGE and ACCEPT that this Declaration shall be governed by the laws of South Africa. I irrevocably agree that the competent Courts of South Africa shall have jurisdiction to hear and determine any suit, action or proceeding, and to settle any dispute which may arise out of, under, or in connection with this Declaration and for such purposes hereby irrevocably submit to the jurisdiction of such Courts. Nothing contained herein shall limit the right of WIM to take proceedings in any other Court of competent jurisdiction nor shall the taking of proceedings in one or more jurisdiction preclude the taking of proceedings in any other jurisdiction whether concurrently or not.
I ACKNOWLEDGE and ACCEPT that this Declaration will be considered as my consent to WIM to disclose, share, record and store this Declaration with any relevant authority or service provider for the purposes of ensuring the safety and security of any and all third parties that may come in contact with me prior, during, and after any visit.