Request edit access
Retrain Back Pain® Medical Waiver, Payment & Coaching Agreement
Your Phone Number
Your Mailing Address
COACHING AND PAYMENT AGREEMENT It’s important that coach and client have a mutual understanding about the procedures and policies that will be in place during the coaching relationship. If there is anything here that is confusing or unclear, please call me discuss before signing this CONFIDENTIALITY: The coach recognizes that the client may share private personal or business information. The coach will not at any time communicate anything that is said in the privacy of a coaching session to a third party except as released by the client or as required by law. PROGRAM AND CANCELLATIONS: New clients must complete the New Client Form prior to scheduling the first session wherein the coach and client begin to establish a relationship. The coach and client will determine the method of contact, scheduled time and telephone number. For all negotiated appointments if the client is not available at that time and arrives within 15 minutes, the session will be shortened. If the client does not contact the coach within 15 minutes, the session will be forfeited. Please remember, cancellations must be made at least 24 hours in advance in order to be rescheduled. NATURE OF RELATIONSHIP: The coaching relationship is in no way to be construed as psychotherapy, psychological counseling, physical therapy or any type of medical advice. In the event that the client feels the need for medical counseling or therapy, it is the responsibility of the client to seek a licensed professional. Client understands that coach is not a licensed health care provider, advisor or consultant and any communications may not be construed as a recommendation of medical treatment or medical advice. It is always the client’s responsibility to seek professional medical or licensed help if it is needed, whether or not the coach makes that recommendation.
I understand and accept these terms
PAYMENT PROCEDURE: The Coach is paid in advance for coaching. The first coaching session will be scheduled once this agreement is signed and the first payment is received. Payment may be made by check, Venmo, Chase QuickPay or Paypal. PAYMENT AGREEMENT: I agree to pay Dinneen Viggiano $150 per 60 minute session. I understand that a 24 hour cancellation policy means that payment will be rendered if cancellation is not communicated within 24 hours of scheduled session. My signature on this agreement indicates full understanding of and agreement with the information outlined on both of these pages. If you are returning this contract by email, please type your name below:
I understand and accept these terms
PROGRAM AND CANCELLATIONS: New clients must complete the New Client Form prior to scheduling the first session wherein the coach and client begin to establish a relationship. The coach and client will determine the method of contact, scheduled time and telephone number. For all negotiated appointments if the client is not available at that time and arrives within 15 minutes, the session will be shortened. If the client does not contact the coach within 15 minutes, the session will be forfeited. *Cancellations should be made via text message (917)579-1155* Please remember, cancellations must be made at least 24 hours in advance in order to be rescheduled.
I understand and accept these terms
ASSUMPTION OF RISK, WAIVER AND RELEASE OF LIABILITY, AND INDEMNITY AGREEMENT DECLARATIONS: This Agreement is entered into between Dinneen Viggiano (Coach) and the undersigned (“Client”). The provision of coaching services by Coach to Client, and Client’s use of any premises, facilities or equipment are contingent upon this Agreement. ASSUMPTION OF RISK: You agree that if you engage in any physical exercise or activity, including personal training, or enter our premises or use any facility or equipment on our premises for any purpose, you do so at your own risk and assume the risk of any and all injury and/or damage you may suffer, whether while engaging in physical exercise or not. This includes injury or damage sustained while and/or resulting from using any premises or facility, or using any equipment, whether provided to you by Trainer or otherwise, including injuries or damages arising out of the negligence of Coach, whether active or passive, or any of Coach's affiliates, employees, agents, representatives, successors, and assigns. Your assumption of risk includes, but is not limited to, your use of any exercise equipment(mechanical or otherwise), sports fields, courts, or other areas, locker rooms, sidewalks, parking lots, stairs, pools, whirlpools, saunas, steam rooms, lobby or other general areas of any facilities, or any equipment. You assume the risk of your participation in any activity, class, program, instruction, or event, including but not limited to weightlifting, walking, jogging, running, aerobic activities, aquatic activities, tennis, basketball, volleyball, racquetball, or any other sporting or recreational endeavor. You agree that you are voluntarily participating in the aforementioned activities and assume all risk of injury, illness, damage, or loss to you or your property that might result, including, without limitation, any loss or theft of any personal property, whether arising out of the negligence of Trainer or otherwise.RELEASE: You agree on behalf of yourself (and all your personal representatives, heirs, executors, administrators, agents, and assigns) to release and discharge Coach (and Coach’s affiliates, related entities, employees, agents, representatives, successors, and assigns) from any and all claims or causes of action (known or unknown) arising out of the negligence of Coach, whether active or passive, or any of Coach’s affiliates, employees, agents, representatives, successors, and assigns. This waiver and release of liability includes, without limitation, injuries which may occur as a result of (a) your use of any exercise equipment or facilities which may malfunction or break, (b) improper maintenance of any exercise equipment, premises or facilities, (c) negligent instruction or supervision, including personal training, (d) negligent hiring or retention of employees, and/or (e) slipping or tripping and falling while on any portion of a premises or while traveling to or from personal training, including injuries resulting from Trainer’s or anyone else’s negligent inspection or maintenance of the facility or premises.INDEMNIFICATION: By execution of this agreement, you hereby agree to indemnify and hold harmless Trainer from any loss, liability, damage, or cost Trainer may incur due to the provision of personal training by Trainer to you. ACKNOWLEDGMENTS: You expressly agree that the foregoing release, waiver, assumption of risk and indemnity agreement is intended to be as broad and inclusive as permitted by the law in the State ofCalifornia and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. You acknowledge that Coach offers a service to his/her clients encompassing the entire recreational and/or fitness spectrum. Coach is not in the business of selling weightlifting equipment, exercise equipment, or other such products to the public, and the use of such items is incidental to the service provided by Coach. You acknowledge and agree that Coach does not place such items into the stream of commerce. This release is not intended as an attempted release of claims of gross negligence or intentional acts.You acknowledge that you have carefully read this waiver and release and fully understand that it is a release of liability, express assumption of risk and indemnity agreement. You are aware and agree that by executing this waiver and release, you are giving up your right to bring a legal action or assert a claim against trainer for Coach’s negligence, or for any defective product used while receiving coaching from Coach. You have read and voluntarily signed the waiver and release and further agree that no oral representations, statements, or inducement apart from the foregoing written agreement have been made.
Typing your name below will serve as binding signature
Thank you for filling out these preliminary forms. I look forward to scheduling our first appointment together, Dinneen
Page 1 of 1
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service