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DAO GAINS
Liability Waiver
First Name
Last Name
Email
Date of Birth
Do you have a doctor’s permit to participate in intense physical activities?
No
Yes
Please specify anything we should know about
Initials
I declare that the info I’ve provided is accurate & complete
I am voluntarily participating in a class or classes provided by [ Benjamin Van Winkle ]. I will be receiving instruction and information concerning fitness and wellness techniques, which may include weight training and other physical activities. I represent and warrant that I have no physical or mental health condition that would prevent my safe participation in these classes. I agree that if I am pregnant, or have a known cardiac arrhythmia (including very slow heart rate), a history of heart block, or if I am taking antipsychotic medications that may result in an adverse reaction in connection with physical activities, I will consult with and obtain the permission of a physician prior to engaging in any weight training or other physical activities in connection with these classes. I am willingly and voluntarily assuming any risks, injuries or damages, known and unknown, which I might incur as a result of participating in these classes, and agree that [ Benjamin Van Winkle ] will not have any liability for such injuries or damages, to the maximum extent allowed by applicable law. I acknowledge and agree that [Benjamin Van Winkle] is not a medical professional and does not provide any medical diagnoses or treatments. I agree that if I have any medical condition, I will seek the help of a medical professional. To the maximum extent permitted by applicable law, I hereby (a) waive and release any claims, known or unknown, I may have against [Benjamin Van Winkle], including his instructors, officers, directors and employees and agents, arising from or in connection with the services provided by [Benjamin Van Winkle] (“Claims”) and agree to indemnify [Benjamin Van Winkle], including its instructors, officers, directors and employees and agents, from and against any and all Claims. I expressly waive all rights afforded by any statute which limits the effect of a release with respect to unknown claims.
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