PROGRAM BACKGROUND (PURPOSE & BENEFITS)

The purpose of this program is to improve the fitness and movement quality of
its participants. Understanding that, I acknowledge that I am not engaging in
physical therapy treatment. Though pain-relief and greater mobility may be
expected benefits of participation in this program, it should not be mistaken
that this is a fitness program. As such, I accept that any fees incurred as a
result of my participation in this program are not eligible for submission to
my health insurance company for reimbursement.

INFORMED CONSENT

I am willingly and of my own volition entering into this training program
conducted by Rebuild Physical Therapy, LLC. I acknowledge that training poses
risks to me including, but not limited to, injury which may vary in severity
from “minor” injury up to and including “severe” injury and potentially death.

I acknowledge my right to withhold or withdraw consent for participation in
this program at any time.

I understand that none of the coaches I may work with through the course of
this program are licensed nutritionists/dietitians. Any conversations
pertaining to the areas of diet, food supplements, weight reduction, and/or
body building enhancement products are intended to provide education and
insight. I acknowledge that any changes I make to my diet or food supplement
intake are entirely my responsibility, and that Rebuild Physical Therapy, LLC.
encourages me to consult a physician prior to undergoing any dietary or food
supplement changes.

WAIVER OF GUARANTEE

I understand that I may expect the anticipated benefits from participating in
this program, but that no results can be guaranteed or assured.

WAIVER OF LIABILITY

I agree to hold harmless and waive all liability against Rebuild Physical
Therapy, LLC, its Managing Partners, and/or representatives, for any injury or
condition, regardless of severity or cause, that may occur due to my
participation in this program.

CONFIDENTIALITY & USE OF INFORMATION

I understand that information obtained as part of this program will be treated
as privileged and confidential and will consequently not be released or
revealed to any person without my consent.

VIRTUAL PROGRAM CONSIDERATIONS

I understand that there are unique risks and consequences associated with
participating in this program due to its virtual/online nature. Those risks
include, but are not limited to, the possibility, despite reasonable efforts on
the part of Rebuild Physical Therapy, LLC, that: the transmission of my
personal information could be disrupted or distorted by technical failures, the
transmission of my personal information could be interrupted by unauthorized
persons, and/or the electronic storage of my personal information could be
unintentionally lost or accessed by unauthorized persons. I accept these risks
as a condition of my participation in this program and agree to hold Rebuild
Physical Therapy, LLC harmless in the event that anything happens to my
personal information.

STATEMENT OF FITNESS FOR TRAINING

I acknowledge that I am in a state of fitness and health that permits safe
participation in an intensive training regimen. I have no known conditions that
would prevent me from exercising safely. I acknowledge that I have the
responsibility to let my coach know when I should not perform a particular
exercise due to any existing limitation.

INTENT

I acknowledge and agree that, not withstanding any parsing of specific language
herein, Rebuild Physical Therapy, LLC and its members and representatives, will
be held harmless and not be held liable for any injury, regardless of severity
or cause, that may occur for any reason as a result of my participation in this
program.