PIT WELD U (PWU) Registration

The information provided in this form is for demographic information related to the participation in Pit Instruction and Training, LLC (PIT) programs. Completion of this form does not suggest or constitute application for or employment by PIT or any of its owners, agents, or affiliates.

Personal Information

Consent Forms

HIPPA CONSENT

HIPAA is the Health Insurance Portability and Accountability Act. This form summarizes important information regarding Pit Instruction and Training, LLC health care services and provides your written consent for treatment/care by Pit Instruction and Training, LLC health care providers and your consent to health care providers to use and disclose your protected health information for treatment, payment for services, and health care operations.   

SERVICES OFFERED

Pit Instruction and Training, LLC may provide a variety of services related to the care, prevention and rehabilitation of injuries incurred by program participants.  Physicians, licensed athletic trainers, physical therapists, massage therapists and other health care providers may provide services at Pit Instruction and Training, LLC facilities.  The health care providers will determine if the care needed involves resources or competencies beyond the scope of available services, and will provide the appropriate referral, documentation, and follow-up.    

CONFIDENTIALITY

Your medical records on file at Pit Instruction and Training, LLC are treated as confidential records and will only be released pursuant to your authorization or as otherwise permitted or required by law.  

CONSENT FOR TREATMENT/CARE

I have read the above material regarding rights and responsibilities of the program participant as it relates to Pit Instruction and Training, LLC.  I understand its provisions, and agree to receive services under the above conditions and I consent to treatment/care, as determined to be necessary by the physicians, licensed athletic trainers, physical therapists, massage therapists and other health care providers.

CONSENT FOR USE AND RELEASE OF INFORMATION

I give permission to Pit Instruction and Training, LLC affiliated health care providers to release any information about me, my health, the health services provided to me, or payment for my health services which may be necessary; 1) For my treatment – to any physician, or other health care providers or facilities which need the information for my continued care; I further authorize Pit Instruction and Training, LLC health care providers and consulting physicians to hospitalize and secure treatment for me for any athletic injuries, 2) For payment purposes – to determine whether I am eligible for insurance coverage and if this treatment/care is authorized for payment by my insurance. This information may also be used to process an insurance claim, for billing and for collection purposes, 3) For Pit Instruction and Training, LLC affiliated health care providers to operate its business more efficiently, and to assess and improve the quality of its health care

ASSUMPTION OF RISK and LIABILITY RELEASE

This exculpatory and assumption of risk agreement, release of liability and covenant not to sue is a legal document. It is referred to as “the Agreement”. The parties to the Agreement are on one hand, myself, my heirs, my personal representatives and all others who may claim by or through me at any time including ant representative(s) of my Estate and, on the other hand, Pit Instruction and Training, LLC (herein after collectively referred to as “PIT”), and any employee, agent, representative, instructor, shareholder, officer, director, subsidiary, affiliate, parent company, successor or assignee of PIT. I agree that my Initials and signature, where indicated in the Agreement, is my binding agreement to and acceptance of the provisions of the Agreement. I will not sign or initial any part of this document unless I fully understand and agree to be bound by its contents. 

VOLUNTARY CHOICE

I desire to participate in PIT programs and activities and have come to participate in PIT programs and activities of my own free will and not due to any inducement or duress whatsoever. I understand that part of the required consideration for being allowed to participate in PIT programs and activities is my execution of all the provisions of the Agreement.

NATURE OF SPORT AND ASSUMPTION OF ALL ASSOCIATED RISKS

I understand that PIT programs and activities and all its attendant activities is a hazardous, dangerous, calculated risk activity that can result in serious, permanent injury, disability or death to its participants. I understand that I can be injured or killed, even if I do everything as I was instructed to do. I am accepting these and all other accompanying risks in order to be allowed to participate in PIT programs and activities of my own free will and with full understanding of the possible consequences and potential dangers, and without inducements, promises or statements other than those contained in the Agreement. I hereby personally assume all risks of any nature for any death, injury or other damages to myself, my property or the property of others which may in anyway, whether foreseeable or not, arise out of my participation in PIT programs and activities or my use of any and all accompanying facilities and equipment, and / or from the actions – specifically including negligent acts or omissions – of all persons involved either directly or indirectly in this activity. I know and fully appreciate that PIT programs and activities expose me to risk of serious personal injury and death and I fully appreciate these dangers and voluntarily assume these risks. 

RELEASE AND WAIVER OF ALL CLAIMS

I, for myself, my heirs, executors, representatives, assigns, successors, administrators and anyone else claiming by or through me, hereby expressly release, discharge, indemnify, hold harmless from and waive any and all claims (including but not limited to claims for property damage, personal injury, and death) whether foreseeable or not – arising from negligence carelessness, gross negligence, willful and wanton conduct, strict liability, or otherwise which I may presently or at anytime in the future possess against anyone associated with these activities including, but not limited to PIT, any employee, agent, representative, shareholder, officer, director, subsidiary, affiliate, parent company, successor, contractor or assignee of PIT, participants, owners and lessees of the premises and facilities and equipment used in connection here within (all of whom are hereinafter referred to as the “Released Parties”) that are involved with or may have any connection, presently or in the future, with my participation in PIT programs and activities. This Release and Waiver is meant to and shall apply to any and all claims, causes of actions, demands, or sums of money that I may have or be entitled to from any Released Parties as a consequence of any type of damage (whether personal or property), loss, death or injury I, or my heirs, representatives, or anyone claiming by or through me has or may in the future have as a consequence of my PIT programs and activities that in any way involve the Released Parties, and regardless of whether the claim, cause of action or demand is grounded in negligence, tort, contract or any other legal basis for the recovery other than intentional conduct specifically intended to injure me. 

COVENANT NOT TO SUE

I agree never to institute any lawsuit or action at law or otherwise against any of the Released Parties, nor to initiate or assist in the prosecution of any claim or cause of action for damages or injury, that I, my heirs, assigns, representatives, successors or administrators may have either now or at anytime in the future by reason of any loss or injury (including death) to my person or property arising from the activities contemplated by or in the Agreement. In the event of a breach of the Agreement by me, my heirs, my estate or anyone acting on my behalf or through me, I agree and warrant that I will be liable to pay each of the Released Parties their actual attorneys fees, court costs, and other expenses caused by such breach. 

CONDITION OF HEALTH

I hereby state and represent that I am in good physical and mental health and am able to withstand the physical and mental stresses inherent in the activities contemplated by the Agreement. I further state and affirm that I am unaware of any health related problem that may affect my ability to participate, if I so chose, in the activities contemplated by the Agreement. I further state and affirm that I am not presently taking drugs, prescriptions or otherwise, including controlled substances. I hereby state and affirm that I will not use alcohol, controlled substances, or other drug, prescriptive or otherwise, prior to or during the activities contemplated by the Agreement at any time. 

TRAINING

I agree that I will not participate in PIT programs and activities unless I have no reservations about such activities and that if I feel, at any time, that I am not qualified or able to participate, regardless of the extent of my training or the application of that training, I will not do so. I affirm and agree that each and every time I participate in the events and activities contemplated by the Agreement, said participation is the sole and conclusive proof that my ability and training were adequate for the risks involved. 

LEGAL AGE TO CONTRACT

I hereby state that I am of lawful age (18 years of age or older) and legally competent to execute the Agreement and further understand that the terms contained herein are contractual in nature, and not a mere recital and that I have executed the Agreement of my own free will. 

CONTINUATION OF OBLIGATION

I hereby agree and acknowledge that all the terms and conditions of the Agreement shall continue in full force and effect now and in the future at all times during which I participate either directly or indirectly in PIT programs and activities or while associated with any of the Released Parties, and all the terms of the Agreement shall be binding upon my heirs, assigns, representatives, successors and administrators of my estate. 

VALIDITY AND ENFORCEABILITY

This is a legally binding contract. If any provision, clause, or portion of the Agreement is illegal or unenforceable, I agree that such determination shall not affect the validity and enforceability of the remaining provisions hereof all of which shall remain in full and effect. I further agree that the proper venue and jurisdiction for enforcement of the Agreement shall be in the State of North Carolina.

ADMINISTRATION

I agree that during and after the term hereof, at the reasonable request of PIT and without further consideration, I will provide information and data and execute and deliver such other documents or take other actions as reasonably may be required to carry out in all respects the Agreement and provisions contemplated herein.

I have carefully read the Agreement in its entirety, without any time constraints being placed upon me and fully understand and agree to be bound by its contents. I am aware that by signing the Agreement I am giving up important legal rights and it is my intention to do so freely and without coercion or duress of any type.

PARENTAL CONSENT FOR A MINOR

I / we know of, and acknowledge that my child/ward knows of, the risks involved in the participation of programs and activities and all its attendant activities, understand that serious injury, and even death, is possible in such participation and choose to accept any and all responsibility for his/her safety and welfare while participating in these activities.

With full under-standing of the risks involved, I / we release hereby expressly release, discharge, indemnify, hold harmless from and waive any and all claims (including but not limited to claims for property damage, personal injury, and death) whether foreseeable or not – arising from negligence carelessness, gross negligence, willful and wanton conduct, strict liability, or otherwise which I may presently or at anytime in the future possess against anyone associated with these activities including, but not limited to PIT, any employee, agent, representative, shareholder, officer, director, subsidiary, affiliate, parent company, successor, contractor or assignee of PIT, participants, owners and lessees of the premises and facilities and equipment used in connection here within (all of whom are hereinafter referred to as the “Released Parties”) that are involved with or may have any connection, presently or in the future, with my participation in PIT programs and activities.

I authorize emergency medical treatment for my child/ward should the need arise for such treatment while my child/ward is under the supervision of PIT. I/we further hereby authorize the use or disclosure of my child’s/ward’s individually identifiable health information should treatment for illness or injury become necessary.

I / we consent to the disclosure, by PIT upon its request, of all records relevant to his / her athletic eligibility including, but not limited to, his/her records relating to enrollment and attendance, academic standing, age, discipline, finances, residence and physical fitness. I / we grant the released parties the right to photograph and / or videotape my child/ward and further to use said child’s/ward’s name, face, likeness, voice and appearance in connection with exhibitions, publicity, advertising, promotional and commercial materials without reservation or limitation. The released parties, however, are under no obligation to exercise said rights herein.

I / we understand that the authorizations and rights granted herein are voluntary and that I / we may revoke any or all of them at any time by submitting said revocation in writing to my school. By doing so, however,

I/ we understand that my / our child / ward will no longer be eligible for participation in PIT activities.

Please complete the following with the appropriate response:

I / WE HAVE READ THIS CAREFULLY AND KNOW IT CONTAINS A RELEASE.

SUBSTANCE ABUSE POLICY

PURPOSE

It is the goal of Pit Instruction and Training, LLC to assure a safe work environment for its contractors and employees and provide quality service for its program participants and customers. To help Pit Instruction and Training, LLC attain these goals, a drug and alcohol-free workplace is necessary.

STATEMENT

Pit Instruction and Training, LLC policy regarding alcohol and other drugs requires compliance with the following rules:

1. The use, possession, solicitation for, or sale of, narcotics or other illegal drugs, alcohol or prescription medication without a prescription, on employer or client premises or while performing an assignment is prohibited.

2. Impairment or being under the influence of legal or illegal drugs or alcohol, on employer or client customer premises or while performing an assignment, is prohibited.

3. The use, possession, solicitation for, or sale of legal or illegal drugs or alcohol off the employer or client customer premises that adversely affects the employee’s work performance, his or her own or others safety at the workplace of the employer or client company’s reputation is prohibited.

4. The distribution or use of controlled substances or illegal drugs at company or customer sponsored functions is prohibited.

Having a measurable presence of any controlled substance or alcohol in the body while at work is prohibited. Violation of any of the above-stated five rules will result in disciplinary action up to and including discharge.

USE OF CONTROLLED SUBSTANCES AS MEDICATION

Although we recognize contractors and employees may be able to report to work while taking medications prescribed by a physician, contractors and employees are expected to discuss the potential side effects of prescribed medication with the prescribing physician. Any question regarding the medication’s effect on the safe and efficient performance of assigned duties must be discussed with Pit Instruction and Training, LLC staff prior to reporting to work.

Contractors and employees must keep all prescribed medicine in its original container, which identifies the drug, date of prescription and prescribing doctor.

DRUG TESTING

Some of our customers require pre-employment drug screening for all contractors and employees placed on assignment at their facility. Contractors and employees will be required to meet the pre-employment drug-screening test before placement with such a customer. Pit Instruction and Training, LLC will require an employee on assignment at a customer’s location to abide by drug or alcohol testing requirements.

Pit Instruction and Training, LLC requires pre-employment drug screening for all contractors and employees placed on driving assignments. An employee may be required to submit to alcohol or controlled substances testing whenever there is reason to believe an employee is using drugs or abusing alcohol in violation of the employer’s or client customer’s controlled substances policies.

Additionally, supervisor may request contractors and employees submit to drug or alcohol testing in connection with a safety investigation, or for random testing. In the event that the Pit Instruction and Training, LLC Substance Abuse Policy is in contrast with a customer’s policy, the more stringent policy shall apply.

REASONABLE SUSPICION

The use of or being under the influence of drugs or alcohol while at work is contrary to this policy. All individuals at work who are believed by supervision to be under the influence of drugs or alcohol must submit to drug or alcohol testing upon request. Reasonable suspicion can occur when an employee’s actions, appearance or conduct are indicative of an employee under the influence of drugs or alcohol, such as erratic behavior or staggering or faltering contractors and employees who test “positive” on reasonable suspicion will be terminated.

TEST RESULTS

Applicants whose tests are returned positive will be given an opportunity to discuss the results with a Medical Review Officer (MRO) to rule out anything that might cause a false positive. Should an employee have a confirmed positive test result, we will be unable to place the employee on any assignment. At management’s discretion, a second screening after 30 days may be granted at the employee’s expense. Any employee testing positive on the second screening will be permanently barred from employment. Any employee who passes the second screening will then be tested for one year on an individual random basis. Any positive test of such random testing will result in discharge.

All positive test results will be confirmed in accordance with all applicable state laws.

INSUBORDINATION AND FALSIFICATION

If an employee refuses to participate in a required alcohol or drug test, or attempts to invalidate the results of the test, the employee will be discharged.

CONFIDENTIALITY

All test results will be treated confidentially and are the sole property of Pit Instruction and Training, LLC.

WHAT DRUGS ARE TESTED?

The company may test for any or all of the following drugs or classes of drugs, and their Metabolites or derivatives, including: marijuana (cannabinoids), cocaine, propoxyphene (Darvon), benzodiazepines, phencyclidine (PCP), methadone, opiates, amphetamines, barbiturates and alcohol. The company also reserves the right to test for other drugs of suspected abuse.

Sample Testing:

Drugs - The Company will use urine, blood, oral fluid, or any of these three, for drug testing. Alcohol - The Company will use breath, urine, blood or any of these three for alcohol testing.

SEARCHES

The company reserves the right to conduct a reasonable, unannounced search of its premises if it believes an employee may be in possession of alcohol or drugs. In special circumstances a law enforcement representative may assist the company in searching an employee and his/her possessions. Refusal to cooperate in a reasonable search will result in discharge.

“Premises” means any company or client customer vehicle, office, factory, warehouse, building, shop, parking lot or property which is owned, leased, rented or operated by the company or client customer; or any other site at which an employee performs company or client customer work.

“Possession” means: on an employee’s person, in an employee’s toolbox, lunch box, brief case or purse; or in and area entrusted to the control of an employee such as a company or client customer vehicle, desk, file, closet or locker.

CONSENT & AUTHORIZATION

Pit Instruction and Training, LLC has customers that have adopted policies requiring pre-employment and reasonable cause drug screening. By signing your name herein below, applicant/employee is expressing a desire for consideration to be assigned to all customers and consents to undergo a drug-screening test prior to beginning work, as required.

Contractor’s and employees agree to supply urine and/or other specimen with the understanding that part of the specimen will be used to test for the presence of illegal drugs, alcohol or controlled substances, and that the result of such test may be disclosed to Pit Instruction and Training and to the customer who requested the screening.

IMAGE AND LIKENESS RELEASE AND WAIVER

For good and valuable consideration, the receipt of which is hereby acknowledged, I hereby consent to the photographing of myself and the recording of my voice and the use of these photographs and/or recordings singularly or in conjunction with other photographs and/or recordings for advertising, publicity, commercial or other business purposes. I understand that the term "photograph" as used herein encompasses both still photographs and motion picture footage.

I further consent to the reproduction and/or authorization by Pit Instruction and Training, LLC to reproduce and use said photographs and recordings of my voice, for use in all domestic and foreign markets.

Further, I understand that others, with or without the consent of by Pit Instruction and Training, LLC may use and/or reproduce such photographs and recordings.

I hereby release Pit Instruction and Training, LLC and any of its associated or affiliated companies, their directors, officers, agents, contractors and employees and customers, and appointed advertising agencies, their directors, officers, agents and contractors and employees from all claims of every kind on account of such use.

PERSONAL INSURANCE PROVISION

I understand and agree that Pit Instruction and Training, LLC does carry necessary and required liability and professional insurance. Pit Instruction and Training, LLC does not assume responsibility of or liability for any health or medical injury claims that may occur during the training or practice or use of any facilities owned or operated by Pit Instruction and Training, LLC during the course of class, travel, practice or competition.

I understand and agree that in case of a medical emergency or injury that may occur at Pit Instruction and Training, LLC, my personal insurance or that of my family is considered primary coverage.

I hereby state that: