Coaching Informed Consent

I do hereby consent to participate voluntarily in a personal fitness training and/or holistic health and wellness coaching program (“Program”) and I recognize this Program may contain certain inherent risks.

I expressly assume the risks of the Program and I take full responsibility for my life and well-being and all decisions made before, during, and after the Program. I understand that the information provided at or in conjunction with the Program, including dietary recommendations and/or supplement advice is not intended to be a substitute for professional medical advice, diagnosis or treatment that can be provided by my physician, therapist, licensed dietitian or nutritionist, or any other licensed or registered health care professional.

I understand that Brandon Kelone and Acacia Fruit Wellness are not medical or mental health care providers and they are not providing health care, medical or nutrition therapy services, or attempting to diagnose, treat or cure in any manner whatsoever, any disease, condition or other physical or mental ailment of the human body. Rather, they are serving only in their capacity as coaches, educators, mentors, and guides.

I agree to seek the advice of my physician or another qualified health care professional prior to and during the Program regarding any questions or concerns I have about my specific health situation, possible or actual pregnancy, known or suspected food sensitivities or allergies, dietary restrictions, or any medications I am currently taking.

I agree to not disregard professional medical advice or delay seeking professional advice or stop taking any medications without speaking to my physician or health care professional.

I agree to disclose to Brandon Kelone and Acacia Fruit Wellness in advance any known or suspected food allergies or sensitivities, any physical limitations that may impact my breathing or movement, or any other health or mental condition that may affect or be affected during the Program. If I suspect that I have a medical problem, I agree to inform Acacia Fruit Wellness and its agent(s) immediately.

I understand that no claim is made as to the certain efficacy of any nutritional or supplement protocols. Additionally, I understand that this program may also include recommendations in regards to bringing balance to the physical, emotional, mental, and spiritual components of my being. These recommendations may include but are not limited to, stress reduction techniques, food modifications, sleep hygiene, corrective stretching and strengthening exercises, range of motion exercises, resistance training, postural exercises, cardiovascular exercise and shoe wear and orthotic recommendations. I understand that adopting any of these recommendations is voluntary and by choice.

I also understand that in some cases lab testing may be recommended as well. If I choose to engage in lab testing, I voluntarily consent to such testing and I fully understand and agree that Brandon Kelone and Acacia Fruit Wellness are not acting as a medical practitioner or providing medical therapy services in any way. I understand and agree that lab testing results and recommendations are not attempting to diagnose, treat, or cure, in any manner whatsoever, any disease, condition or other physical or mental ailment of the human body. Rather, I understand and agree that the lab testing results are shared with me for purely educational and informative purposes.

I fully understand that all lifestyle recommendations, including but not limited to physical exercise and food are designed with my health, well-being and utmost safety in mind. I have been informed and understand physical exercise and food modifications have been associated with certain risks, including but not limited to, musculoskeletal injury, spinal injuries, abnormal blood pressure responses, respiratory distress, and in rare instances heart attack or death. Every effort will be made to minimize these risks.

Any information that is obtained from my medical history, fitness level, and coaching sessions will be treated as privileged and confidential and will not be released or revealed to any person, including my healthcare provider(s) without my expressed written consent.

In the event that I may injure myself or become ill as a result of my participation in this program, I hereby release, discharge, and waive any and all liability, damages, causes of action, allegations, suits, sums of money, claims, and demands which I have ever had, now have, and could have in the future against Brandon Kelone and/or Acacia Fruit Wellness, arising from my participation in anything related to the Program, now or in the future.

By filling my name and marking the boxes below, I certify that I have carefully read this document I consent to all parts of it. I understand that by filling my name and marking the boxes below this release, I voluntarily surrender certain legal rights.

First Name

Last Name

Legal Guardian First Name if under 18

Legal Guardian Last Name if under 18

Today's Date

Phone Number

I have read and understand all of the information listed in this Informed Consent document.

I hereby acknowledge this release from liability for accidental injury or illness which I may incur as a result of participating in any physical activity or health and wellness coaching program. I hereby assume all risks connected therewith and consent to participate in this program. I agree to disclose my physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in this program.

Submission Complete!

Return to Previous Page