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If taking part in the HDT Nutrional program & coaching with Kimberly McGrath of Modus-Energy you must sign the following waiver.

In consideration of being allowed to participate in the activities and programs offered by Modus Energy, LLC, and to use its nutrition programs and training, in addition to the payment of any fee or charge, I do hereby waive, release and forever discharge and hold harmless Modus Energy, LLC and its officers, agents, consultants/coaches and employees from any and all responsibility, liability, cost and expenses, including injuries or damages, resulting from my participation in any activities, or my use of any programs designed by Modus Energy, LLC. I do also hereby release Modus Energy, LLC its officers, agents, consultants/coaches and employees from any responsibility or liability for any injury or damage to myself, or in any way arising out of or connected with my participation in any activities with Modus Energy. The nutrition information provided by Modus Energy LLC is provided for informational purposes only and represents the sole opinion of the owner. Modus Energy, LLC does not provide medical advice, and the information provided is not intended to diagnose, treat, cure, or prevent any illness or disease.  Any person involved in an exercise or diet program assumes his or her own risks.  Always consult with your physician before changing your diet or activity. I hereby agree to expressly assume and accept any and all risks of injury or death related to said program.

I do hereby further declare myself to be over the age of 18, physically sound and suffering from no condition, impairment, disease, infirmity or other illness that would prevent my participation in a diet program or training program except as hereinafter stated. I do hereby acknowledge that Modus Energy, LLC has recommended to me that I obtain a physician’s approval for my participation in a diet or training program, in an exercise/fitness activity or in the use of exercise equipment and machinery. I also acknowledge that Modus Energy, LLC has recommended that I have a yearly or more frequent physical examination and consultation with my physician as to participation in a calorie restricted diet program, physical activity, exercise and use of exercise and training equipment so that I might have his/her recommendations concerning these diet and fitness activities and equipment use. I acknowledge that I have either had a physical examination and been given my physician’s permission to participate, or that I have decided to participate in programs designed by Modus Energy, LLC without the approval of my physician and do hereby assume all responsibility for my participation and activities, and utilization of equipment and machinery in my activities. In addition, I hereby represent and warrant that I am currently covered by an accident and health insurance policy.

 

I understand that payment for consulting services is non-refundable.

I understand that all written and oral information and materials disclosed or provided by Modus Energy LLC under this agreement constitutes Confidential Information regardless of whether such information was provided before or after the date of this agreement, or the medium in which it was provided. I agree not to share Confidential Information provided by Modus Energy LLC with any other individual or party. Confidential Information may not be reproduced, transformed, or otherwise shared without express written permission by Modus Energy LLC.

 

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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