5-MINUTE STRETCH RELIEF SESSION WAIVER FORM

WAIVER OF LIABILITY & ASSUMPTION OF RISK AGREEMENT

NOTICE: THIS A BINDING CONTRACT WITH LEGAL CONSEQUENCES. PLEASE READ CAREFULLY BEFORE SIGNING.

In consideration for receiving personal training and/or massage services from Ventus Therapy LLC and one or more of its Affiliates, as herein defined (jointly and severally referred to as “Affiliate”), I hereby freely and voluntarily agree to the following representations, waivers and agreements:

I know and understand that Affiliate is a strength and conditioning personal trainer, physical therapist assistant, wellness/fitness practitioner, and/or massage therapist and that the sport of strength and conditioning training is an action sport which carries significant risks of serious personal injury, death and property damage, including, without limitation, sprained or strained muscles, broken bones, and cardiac arrest. I also know and understand that while participating in and/or training for this sport, I am exposed to many natural, mechanical and environmental conditions and risks which independently or in any combination with my activities and those of others may cause bodily injury and/or property damage, including but not limited to, severe or even fatal injuries to myself or others. These risks include the unavailability or inadequacy of emergency medical care or first aid treatment, and my becoming unconscious or incapacitated such that I cannot make decisions regarding my medical care.


I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow. If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session. I understand that the services offered today are not a substitute for medical care. I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness. I affirm that I have notified my therapist of all known medical conditions and injuries. I agree to inform the therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapist’s part should I forget to do so. I understand that massage is entirely therapeutic and non-sexual in nature.


I agree that I alone am responsible for: (a) my proper preparation and safety while participating in any event or activity directed or recommended by Affiliate; (b) providing, utilizing and maintaining the equipment necessary for the safe enjoyment of my participation in any such event or activity; and, (c) wearing properly functioning protective equipment while participating in any such event or activity. I also represent that I have no physical or medical condition which, in my knowledge, would endanger myself or others while I participate in this sport or any event or activity directed or recommended by the Affiliate.

Informed Consent

I understand that attending Affiliates are not licensed physicians and are unable to cure, diagnose, mitigate, prevent, or treat conditions. Services provided by the Affiliate are for pain reduction and increased circulation. Light therapy should not be used as a replacement for medical treatment from a licensed physician or other healthcare provider. I have been informed that light therapy is generally safe. While side effects are not common, if they do occur, they’re usually mild and short lasting. They may include: Increased sensation, itching, or pain to the treated area due to increased circulation, elevated temperature, skin irritation or uncomfortable warmth on the treated area due to increased circulation, eyestrain / headache.

This agreement is made upon the express condition that the Affiliate and device manufacturer shall be free from all liabilities and claims for damages and/or suits for or by reason of any injury, or death to any person or property of the client while in or upon said premises of services given or any part thereof during sessions of this agreement in connection herewith, and the client hereby agrees to hold harmless the Affiliate and device manufacturer from all liabilities, charges, expenses and costs on account of or by reason of any such injuries, deaths, liabilities, claims, suits, damages, or losses however occurring out of each session.

By signing below, I agree that information I have provided is accurate to the best of my knowledge. I have read and understand all above information, and give my full consent to receive light therapy from the Affiliate. I acknowledge that this consent is given of my own free will and conscience, with no outside sources affecting my decisions, and that any questions have been answered by the Affiliate.

Being fully aware of the risks, conditions and hazards associated with this sport and my participation in training sessions, events and activities directed or recommended by the Affiliate, I HEREBY ACKNOWLEDGE AND AGREE AS FOLLOWS:


1. Affiliate is not in any way responsible for my health or safety while participating in any training program, training session, competition, race, event or any other activity of any kind directed or recommended to me by Affiliate.


2. For and on behalf of myself and each of my family members, guests, heirs, executors, administrators, representatives, insurers, successors, assigns and agents (hereinafter, “successors”), I HEREBY FULLY AND FOREVER release, remise, acquit and discharge Affiliate, its owners, members (specifically including, without limitation, YOSHIYA CHIBA, managers, directors, officers, employees, partners, subsidiaries, independent contractors, agents, representatives, attorneys, insurers, successors, and assigns (jointly and severally called “Affiliates”), and each of them, from any and all actions, suits, claims, demands, damages, liabilities, obligations, debts, judgments and liens of every kind whatsoever (including, without limitation, those based upon negligence, wrongful death, premises liability, and breach of warranty), which I may now or hereafter have relating to or arising out of my participation in any training program, training session, competition, race, event or any other activity of any kind directed or recommended to me by Affiliate, whether such injury, death or damage was the result of negligence or carelessness on the part of Affiliate or otherwise, and regardless of whether such injury, death or damage was foreseeable.

I specifically intend the foregoing to be a general release of all claims and waive any rights I may have with respect to unknown claims under the laws of New York. Accordingly, I hereby waive any rights or benefits I may have under New York Civil Practice Law and Rules Section 4547, or any similar laws, which provides: "A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS WHICH THE CREDITOR DOES NOT KNOW OR SUSPECT TO EXIST IN HIS OR HER FAVOR AT THE TIME OF EXECUTING THE RELEASE, WHICH IF KNOWN BY HIM OR HER MUST HAVE MATERIALLY AFFECTED HIS OR HER SETTLEMENT

WITH THE DEBTOR."

A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS WHICH THE CREDITOR DOES NOT KNOW OR SUSPECT TO EXIST IN HIS OR HER FAVOR AT THE TIME OF EXECUTING THE RELEASE, WHICH IF KNOWN BY HIM OR HER MUST HAVE MATERIALLY AFFECTED HIS OR HER SETTLEMENT WITH THE DEBTOR.

1. I shall not file any claim, lawsuit or other proceeding, whether judicial or administrative,

for any personal injury, death, property damage, loss, or other injury or damage suffered

by me (including but not limited to negligence, wrongful death, premises liability, and

breach of warranty claims) as a result of my participation in any training program,

training session, competition, race, event, or any other activity of any kind directed or

recommended to me by Ventus Therapy LLC.

2. I shall indemnify, defend, and hold harmless Ventus Therapy LLC and its owner, Yoshiya Chiba,

from and against any and all actions, suits, claims, demands, losses, damages, liabilities,

obligations, debts, judgments, and liens of every kind whatsoever to which Ventus Therapy LLC

or Yoshiya Chiba is subjected, or which may be asserted against Ventus Therapy LLC or Yoshiya

Chiba by any person or entity, relating to or arising out of my participation in any

training program, training session, competition, race, event, or any other activity of any

kind directed or recommended to me by Ventus Therapy LLC, and any claim asserted by me or

my successors in contravention of this agreement. Any defense of Ventus Therapy LLC or

Yoshiya Chiba required of me hereunder shall be by counsel reasonably acceptable to the

party being defended, whose fees and costs shall be paid by me, and I shall not seek any

contribution or reimbursement from such party for such fees or costs.

3. I represent that I am at least eighteen years old, unless this agreement is signed below by

a parent or guardian. I consent to Ventus Therapy LLC seeking reasonable and necessary medical

treatment for me during my participation in any training program, training session,

competition, race, event, or any other activity of any kind directed or recommended to me

by Ventus Therapy LLC if I am unable to act on my own behalf. I expressly authorize any

emergency first aid, medication, medical treatment or surgery deemed necessary by

attending medical personnel if I am not able to act on my own behalf, and agree to be

responsible for any cost of such treatment.

This is the only agreement between Ventus Therapy LLC, Yoshiya Chiba, and me concerning the subject matter hereof, and no promise, oral statement, representation, warranty, or commitment of any kind has been made to me concerning the subject matter hereof, which is not set forth herein. This agreement can be modified or terminated only by a written agreement signed and dated by

Yoshiya Chiba, or any authorized officer of Ventus Therapy LLC, and by me specifically referencing this agreement and the waiver or modification to be so made, and no provision hereof can be modified or waived by any course of performance or dealing of Ventus Therapy LLC, or any agent or representative of Ventus Therapy LLC, under the laws of New York.