BRCA in BC March 21 Registration

BRCA in BC Registration 2024-2025

InspireHealth BRCA Registration

"*" indicates required fields

Which BRCA Session are you registering for?*

Have you previously registered as a patient or support person at InspireHealth?*

Current Patient or Support Person Contact Information

Name*

First Last

Date of Birth*

Phone*

Email*

Enter Email Confirm Email

Address*

City Province Postal Code

New Patient or Support Person Contact Information

Yes, I would like to register as a patient or support person with InspireHealth to access free supportive cancer care programs and services.

Name*

First Last

Preferred name (if different from above)

Primary Phone*

Mobile Phone

Date of Birth*

Email*

Enter Email Confirm Email

Address*

Street Address Address Line 2 City Province Postal Code

What is your gender?*

Have you been diagnosed with cancer or with a genetic predisposition to cancer?*

Yes

No - I am a support person

Please specify cancer or genetic diagnosis:*

Please name the patient you are supporting:*

Patient Provincial Health/BC Care Card Number:

Support Person Provincial Health/BC Care Card Number:

Emergency Contact Information

Full Name Relationship

Emergency Contact Phone

How did you hear about InspireHealth?

Please specify who: (e.g. BC Cancer, BRCA in BC Canadian Cancer Society (CCS), CCS lodge, doctor/physician, healthcare professional, friend, family member, online search or other).

Monday 3:00 pm PT

Thursday 5:00 pm PT

Friday 11:00 am PT

I would like to subscribe to the InspireHealth Newsletter and receive upcoming programs, news, events and giving opportunities.

I would like to receive reminders about upcoming programs and classes.

InspireHealth Patient and Support Person Liability Waiver*

Assumption of Risk, Release of Liability, Waiver of Claims, and Indemnity Agreement

ASSUMPTION OF RISKS
I have voluntarily chosen to participate in classes, programs, services, and/or consultations with InspireHealth Society (“InspireHealth”) medical doctors, clinical counsellors, dietitians, exercise therapists and/or other InspireHealth team members or practitioners (the “Services”). The Services may be provided remotely and/or may be provided at an InspireHealth location in Vancouver, Victoria, Kelowna or elsewhere (the “Facilities”).

1. I am aware and understand that there are risks when I participate in the Services and/or use InspireHealth Facilities. Some risks can be anticipated and some cannot.
2. The risks of participating in the Services and of using InspireHealth Facilities include, but are not limited to risks of physical injury, examples of which include: shortness of breath, dizziness, exacerbation of symptoms of my cancer or cancer treatment, increased risk of slips, trips or falls, pain of unknown origin, strains, sprains, overexertion, dehydration, fatigue, aggravation of pre-existing conditions, headaches, tingling or other unusual physical sensations, weakness, nausea, serious injury, permanent or temporary disability, death; risk of adverse psychological effects or of psychological injury, examples of which include: anxiety, depression, irritability, nervousness, trouble sleeping, thoughts of self-harm; property damage; and social or economic losses.
3. Even if InspireHealth has assessed me and provided clearance for me to participate in the Services, this does not eliminate the risks.
4. I am aware of the contagious nature of bacterial and viral diseases including the 2019 novel coronavirus disease (COVID-19) (the "Disease") and that despite any efforts by InspireHealth to reduce the risk of exposure, I may be exposed to or contract the Disease by participating in the Services, by attending InspireHealth Facilities and/or by interacting with InspireHealth staff, contractors and/or members, and that the Disease may result in serious illness, physical injury, disability, death, expenses or other losses.
5. I understand, acknowledge and accept that negligent acts, omissions, advice, or a negligent failure to warn, protect or advise me on the part of InspireHealth and/or its officers, directors, employees, contractors, consultants, volunteers, agents, instructors, therapists, insurers, sponsors, donors, representatives, members, successors, assigns may cause or increase the risk that I will suffer physical injury, psychological injury, property damage, and social or economic loss.

I UNDERSTAND, ACKNOWLEDGE AND AGREE THAT I AM VOLUNTARILY PARTICIPATING IN THE SERVICES and/or ATTENDING THE FACILITIES, KNOWING THAT THERE ARE RISKS TO DOING SO. I AGREE TO ACCEPT AND ASSUME ALL RISKS OF PHYSICAL INJURY, PSYCHOLOGICAL INJURY, PROPERTY DAMAGE, SOCIAL AND ECONOMIC LOSS, DISABILITY, DEATH, AND ANY OTHER LOSS OF ANY KIND WHATSOEVER ARISING FROM OR IN ANY WAY CONNECTED WITH THE SERVICES, MY PARTICIPATION IN THE SERVICES AND/OR MY ATTENDANCE AND USE OF THE FACILITIES, INCLUDING THOSE CAUSED OR CONTRIBUTED TO BY THE NEGLIGENCE OF INSPIREHEALTH OR OTHERS FOR WHOM OR FOR WHICH INSPIREHEALTH IS RESPONSIBLE AT LAW.

RELEASE OF LIABILITY and WAIVER OF CLAIMS
As a precondition to participating in the Services, and as consideration for the value that I will receive by participating in the Services, I agree to all the terms and conditions in this Assumption of Risk, Release of Liability, Waiver of Claims, and Indemnity Agreement (“Agreement”).

I EXPRESSLY WAIVE ANY AND ALL CLAIMS which I have or which I may, in future, have against InspireHealth and/or its officers, directors, employees, contractors, consultants, volunteers, agents, instructors, therapists, insurers, sponsors, donors, representatives, members, successors, assigns and/or anyone who or which might claim contribution or indemnity from any one of them (collectively, the “Releasees”) DUE TO ANY CAUSE WHATSOEVER AND HOWSOEVER ARISING, including on account of any PHYSICAL INJURY, PSYCHOLOGICAL INJURY, PROPERTY DAMAGE, SOCIAL AND ECONOMIC LOSS, DISABILITY and/or, DEATH, examples of which are referred to above in the “Assumption of Risks” section of this Agreement, and including those arising from, or in any way connected to the Services, my participation in the Services, and/or my attendance at and/or use of InspireHealth Facilities.
For greater certainty, I expressly waive my right to seek compensation from any of the RELEASEES FOR ANY REASON WHATSOVER, including but not limited physical injury, psychological injury, property damage, social or economic loss, death and/or disability caused by negligent acts, omissions, advice, or a negligent failure to warn, protect or advise me by any of the RELEASEES, including any breach of any duty of care owed to me pursuant to the Occupiers Liability Act, R.S.B.C. 1996, c. 303, as amended.
I covenant not to make or bring any such claims against InspireHealth or any of the Releasees, and forever release and discharge InspireHealth and the other Releasees from liability under such claims.

INDEMNITY
I AGREE TO HOLD HARMLESS AND INDEMNIFY InspireHealth and the other RELEASEES from and against any injury, loss, damage, expense. liabilities, deficiencies, claims, actions, judgments, settlements, interest, awards, penalties and fines OF ANY KIND WHATSOEVER and arising from or in any way connected with my membership with InspireHealth, my participation in the Services, and/or my attendance at or use of the Facilities, INCLUDING ALL RISKS AND CAUSES REFERENCED IN THE ASSUMPTION OF RISK AND RELEASE OF LIABILITY AND WAIVER OF CLAIMS sections of this Agreement, above.

ADDITIONAL TERMS
I further acknowledge and agree that:
1. Entire Agreement: This Agreement is the entire agreement between me and InspireHealth governing my participation in the Services and use of the Facilities.
2. Severability: If any term or provision of this Agreement is invalid or unenforceable for any reason, it shall be severed and not affect the validity and enforceability of the remaining terms or provisions.
3. Binding Agreement: This Agreement is binding on and shall benefit me, InspireHealth, the other Releasees and our respective heirs, executors, administrators, successors and assigns.
4. Governing Law: All matters arising out of or relating to this Agreement shall be governed by and construed in accordance with the laws of the Province of British Columbia and the federal laws of Canada applicable within that Province. Any claim or cause of action arising under this Agreement may be brought only in the courts of the Province of British Columbia, and I hereby consent to the exclusive jurisdiction of such courts.

I acknowledge and agree that by signing this Agreement, I HAVE READ AND UNDERSTOOD ALL OF THE TERMS OF THIS AGREEMENT AND THAT I AM VOLUNTARILY GIVING UP SUBSTANTIAL LEGAL RIGHTS (on my behalf and on behalf of my heirs, executors, administrators, and next-of-kin), INCLUDING THE RIGHT TO SUE INSPIREHEALTH AND THE OTHER RELEASEES FOR ANY REASON WHATSOEVER.

I am 19 years of age or older and not under a legal disability.

I agree to the Terms of Service