Liability Waiver and Assumption of Risk
Kelly Six, PN-1, CF-L1
In consideration of the services of Kelly Six, I hereby agree to release and discharge Kelly Six, on behalf of myself, my children, my parents, my heirs, assigns, personal representative and estate as follows:
1. By accepting these terms, I will not hold Kelly Six, responsible for any injury, illness, allergic reaction or lack of results while engaged in a diet, nutrition, or fitness program or at any time in the future. I acknowledge that Kelly Six is NOT a physician, psychologist, licensed dietician, or licensed nutritionist and CANNOT diagnose or prescribe medications or recommend any changes in medications. I completely acknowledge that I am simply receiving advice and that it is my choice to adhere to the provided advice. My participation in this program is voluntary, and by signing this waiver, I accept responsibility for any harm, injury, illness, or death that may result from my participation.
2. I understand that it is my responsibility to consult with my physician before starting a nutrition and fitness program with Kelly Six. I hereby affirm that I am in good physical condition and do not suffer from any mental or physical disability which would prevent or limit my participation in a program provided by Kelly Six. I acknowledge that if I believe I have an ailment or illness that may require medical attention, Kelly Six has encouraged me to consult with a licensed physician without delay. I understand that Kelly Six will not be held liable for failure to diagnose or treat an illness, nor will she be liable for failure to prevent an illness.
3. I understand that I am participating in a program that may include strenuous activity with the use of conditioning and exercise equipment if discussed during individual programming.
4. I fully understand that I may suffer injury and even death as a result of my participation in the program and I hereby release Kelly Six from any and all liability now and in the future, including but not limited to medical expenses, lost wages, pain and suffering that may occur by reason of heart attacks, muscle strains, pulls or tears, broken bones, heat prostration, soreness or injury, and any other illness, however caused, whether occurring during or after my participation in the program regardless of fault.
5. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless Kelly Six from any and all claims, demands, or causes of action, which are in any way connected with my participation in the diet or training program, including such claims which I, my children, parents, heirs, assigns, personal representative and estate have or may have that allege ordinary negligent acts or omissions of Kelly Six.
6. Any advice regarding dietary supplements provided by Kelly Six is strictly done so by opinion only, and these products may not have been approved by the FDA. Any companies or products mentioned by Kelly Six are not affiliated with Kelly Six and Kelly Six is not liable for any negative repercussions. By agreeing to these terms, I am accepting that I will not hold Kelly Six accountable for any issues, health related or non-health related that may result from consuming a product suggested or recommended by Kelly Six. I understand that I am responsible for understanding my own body and the health risks involved in consuming a dietary supplement.
7. I agree that the forgoing liability waiver and assumption of risk agreement is intended to be broad and inclusive as permitted by the law of the Commonwealth of Virginia.
8. I have read this liability waiver and assumption of risk and fully understand its terms. I understand that I am giving up my right to sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law in the Commonwealth of Virginia.
By checking box and entering my name below, I agree I have received, read, and understand the terms and conditions. I agree to the terms and conditions stated herein and agree this electronic signature is legally binding.
Please check box to consent to above statement and type name below.
Type name below
Photography Consent Form
Eclectic Wellness, LLC would like to use your progress measurements and progress photos for promotional purposes. You may select the option of having your identity (face blurred, name and identifying information) withheld. Photos may be used in social media, website, and print. You may also choose to be contacted before use of photos and provide your own chosen progress photos for Eclectic Wellness' use. Please read the statements below carefully and check all that apply, then type or sign your name below.
Photography Consent Form
I agree to my photos and measurements being used by Eclectic Wellness with my likeness and identity associated with the photos.
I agree to my photos and measurements being used by Eclectic Wellness with my likeness and identity withheld.
I DO NOT agree for my photos to be used in associated with Eclectic Wellness, LLC.
I would prefer to be contacted before usage and provide my own chosen progress pictures instead of those chosen during service meetings,
Type Name Below
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service