Self-Actualization Coaching Waiver

Agreement, Release & Waiver of Liability for Self-Actualization Coaching

By electronically initialing each section and signing this form at the end, I indicate I agree to the following:

I am 18 years old or older *

Yes No

*If you are not 18 years old, you are not eligible to participate in this program.
* If you are 18 years of age or older, please complete with the rest of this form prior to your first coaching session.

* Indicates required field

1. I understand and agree that I am fully responsible for my choices and decisions that impact my well-being during and after coaching sessions. *

2. I understand that all content offered by Creating Momentum Coaching (CMC) is solely for my personal use in achieving my personalized goals. I understand that I have the ability to give informed consent, and hereby gives such consent to the coach in assisting me in achieving such goals. *

3. I understand that coaching is an unregulated industry and that CMC or its employees cannot be and therefore are not licensed by the State of New Jersey or any other state. I understand that for all legal purposes, the services provided by CMC will be considered to be provided in the State of New Jersey. *

4. I understand that I should receive a physical examination by a physician prior to commencing any new wellness, fitness, and/or exercise program, or initiating a substantial change in diet. If I chose not to obtain medical clearance prior to beginning any service offered by CMC, I hereby agree that I am doing so solely at my own risk. I acknowledge and agree that I assume the risks associated with any and all wellness, nutrition, and exercise related activities in which I participate. *

5. I understand that any service offered by CMC is not offered as a substitute for professional medical care and is not intended to diagnose, treat, or cure any medical conditions. I understand that the Coach is not acting as a medical professional. I understand that this service is not a substitute for physical therapy, medical nutrition therapy, licensed mental health therapy, and/or substance abuse treatment, and I will not use this coaching service in place of any form of therapy or treatment listed or not listed here. *

6. I understand CMC will protect my information as confidential unless I provide consent to share my information either verbally or in writing. If I imply, indicate, report or threaten to harm myself or someone else, I understands that this may necessitate action by CMC and my confidentiality agreement is limited in this capacity. *

7. I understand and am aware that any wellness, exercise, or fitness activities may cause injury. I understand that there is an inherent risk of injury when choosing to participate in any wellness, exercise or fitness activities. I also have been informed of, understand and are aware that any wellness, exercise and/or fitness activities involve a risk of abnormal changes in blood pressure, fainting, and a remote risk of heart attack, stroke, other serious disability or death. My participation is a voluntary activity in all respects and I assume all risk of injury (including death), illness, damages or loss that may result from such participation in any and all activities arising out of, connected with, or in any way associated with wellness activities. I acknowledge that participation in these activities is voluntary. *

8. I, on behalf of myself , do hereby fully release and discharge CMC and their agents and employees ("Released Parties") from any and all liability, claims, and causes of action from injuries or illness (including death), damages or loss which I may have or which may accrue to me on account of participation in coaching services. This is a complete and irrevocable release and waiver of liability. Specifically, and without limitation, I, on behalf of myself, hereby release the Released Parties from any liability, claim, or cause of action arising out of the Released Parties’ negligence. I, on behalf of myself, covenant not to sue the Released Parties for any alleged liabilities, claims, or causes of action released hereunder. *

9. I agree to indemnify and hold harmless and defend the Released Parties from any and all claims resulting from injuries or illness (including death), damages, or loss, including, but not limited to attorneys’ fees, sustained by me arising out of, connected with, or in any way associated with my participation in wellness activities. *

10. In the event of any emergency, I authorize the Released Parties to secure from any licensed hospital, physician and/or medical personnel any treatment deemed necessary for my immediate care and agree that I will be responsible for payment of any and all medical services rendered. *

I understand that my signed agreement, and release & wiaver liability will be retained in my client personnel file. This document is binding upon me and my heirs, children, wards, personal representatives and anyone else entitled to act on my behalf.

By electronically signing the form below, “I Accept” all of the terms initialed by me above.

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Emergency Contact's Information:
In the unlikely event that an emergency arises during our coaching sessions, whom may I contact to bring you emergency assistance?

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