• Naval Square Kickboxing Liability Waiver

    Coach Ben Philly of Broad Street Kickboxing
  • LIABILITY WAIVER


    This Liability Waiver (this “Agreement”), dated as the date set forth adjacent to the
    signatures hereto (the “Date”), is by and between Benjamin Thieberger, (“Coach Ben”) and the undersigned Client (“Client”). In consideration of premises and mutual covenants whereas, Client desires to receive certain consulting services from Coach Ben, and Coach Ben desires to provide such services on the terms and conditions set forth herein. For mutual consideration, the receipt and sufficiency of which is hereby acknowledged, Client and Coach Ben hereby agree as follows:


    In consideration of being allowed to participate in the activities and services offered by Coach Ben, and to use its programs and training, in addition to the payment of any fee or charge, I do hereby waive, release and forever discharge and hold harmless Coach Ben 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 Coach Ben.


    I understand and am aware that strength, flexibility, and aerobic exercise, including the use of equipment are potentially hazardous activities. I also understand that fitness activities involve a risk of injury and even death and that I am voluntarily participating in these activities and using equipment and machinery with knowledge of the dangers involved. I hereby agree to expressly assume and accept any and all risks of injury or death related to said fitness activities.

    I do hereby further declare myself to be physically sound and suffering from no condition, impairment, disease, infirmity or other illness that would affect nutrient metabolism or prevent my participation or use of equipment or machinery except as hereinafter stated. I acknowledge that my Coach Ben has recommended that I have a yearly or more frequent physical examination and consultation with my physician as to physical activity, exercise and use of exercise and training equipment so that I might have his/her recommendations concerning these 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 activity and use of equipment, machinery, and programs designed by Coach Ben 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.


    By selecting "AGREE" and signing below, you agree to the terms set forth in this Liability Waiver, and acknowledge that you have been given the opportunity to read them. Please type your full name and sign below.

  • Photo/Video Release

    I hereby grant Coach Ben Philly permission to use my likeness in a photograph, video, or other digital media (“photo”) in any and all of its publications, including web- based publications, without payment or other consideration.

    I understand and agree that all photos will become the property of the Coach Ben Philly and will not be returned.

    I hereby irrevocably authorize the Coach Ben Philly to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo.

    I hereby hold harmless, release, and forever discharge the Coach Ben Philly from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

    I HAVE READ AND UNDERSTAND THE ABOVE PHOTO RELEASE. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM UNDER 18 YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENTS/GUARDIANS AS EVIDENCED BY THEIR SIGNATURES BELOW. I ACCEPT:

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