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Basic Program & Service Policies

Client agrees that enrollment into MBS CONNECTION® Owned & Operated by MBS Association, LLC programs and/or services is being made of their own free will. Client in no way was coerced into enrolling in an MBS CONNECTION® Owned & Operated by MBS Association, LLC program or forced to participate in any service provided by MBS CONNECTION® Owned & Operated by MBS Association, LLC.

Client agrees to be on time for all scheduled training sessions and/or service appointments provided by MBS CONNECTION® Owned & Operated by MBS Association, LLC. Client understands and agrees that MBS CONNECTION® Owned & Operated by MBS Association, LLC, trainers and/or coaches will wait for no longer than (15) fifteen minutes for a late Client. After a period of (15) fifteen minutes MBS CONNECTION® Owned & Operated by MBS Association, LLC trainers and/or coaches will no longer wait, and Client forfeits their training or service session. Client understands and agrees that no credit shall be given for session loss.

Client agrees to be on time for all small group training sessions. Client acknowledges that small group training sessions are to start and end on time and MBS instructors, trainers and/or coaches will not permit Clients who are late to enter small group training facilities. No late admittance to small group training and/or boot camps will be permitted. Client will forfeit their small group training session and/or boot camp session in the event of a late arrival.

Cancellation Policy:

Client understands and agrees that all cancellations are to be made a minimum of (24) twenty-four hours in advance or they will forfeit their training and/or service session. Client acknowledges that if they need to cancel a training and/or service session; this must be done with a minimum of (24) twenty-four hours’ notice and done so by phone or email. Please call 609-401-2373 or email compliance@mbscnj.com to reschedule your appointment and not forfeit your training or service session.

Client acknowledges that; Client received, reviewed and completed all health risk screening paperwork. Client acknowledges that all health risk screening forms were completed thoroughly and honestly and that there has been no medical or lifestyle information withheld from MBS CONNECTION® Owned & Operated by MBS Association, LLC at the time of health risk screening assessment.

Client’s Health Warranty:

Client acknowledges that; Client has no impairment, disability or ailment preventing him/her from engaging in active or passive exercise, or that will be detrimental or averse to such a person’s health, safety, or physical condition if he/she does engage or participate. Client acknowledges and agrees that: (1) MBS CONNECTION® Owned & Operated by MBS Association, LLC rely on the foregoing warranty in issuing enrollment in program and/or services; (2) MBS CONNECTION® Owned & Operated by MBS Association, LLC have no obligation to perform a fitness assessment or similar testing to determine the Client’s physical condition; (3) if any fitness assessment or similar testing is performed by MBS CONNECTION® Owned & Operated by MBS Association, LLC, it is solely for the purpose of providing comparative data with which the Client can track progress in a program and/or service and is not for diagnostic purposes. (4) MBS CONNECTION® Owned & Operated by MBS Association, LLC shall not be subject to any claim, demand or injury whatsoever on account of the MBS CONNECTION® Owned & Operated by MBS Association, LLC evaluation or interpretation of such fitness assessment or similar testing. (5) MBS CONNECTION® Owned & Operated by MBS Association, LLC shall not be liable for any injury arising out of Client’s disability, impairment or aliment preventing him/her from engaging in active or passive exercise, or that would be detrimental or averse to such a person’s health, safety or physical condition if he/she does so engage or participate. Each Client should be aware of his/her medical history and should consult with a physician prior to engaging in exercise if medical condition appears or appears to be developing.

Client acknowledges that they have reviewed, understands and signed a Release of Liability Form, Informed Consent Form for Exercise Testing and Informed Consent for Training and/or Coaching Program(s). Client acknowledges that they signed the aforementioned forms of their own free will.

Release of Liability:

Client acknowledges that the individual training, small group training, nutritional guidelines, wellness or intensive coaching programs and/or services purchased hereunder includes participation in strenuous physical activities, including, but not limited to, running, weight training, stationary bicycling, gymnastic movements, various aerobic conditioning machinery and various nutritional programs offered by MBS CONNECTION® Owned & Operated by MBS Association, LLC. Client acknowledges these activities involve inherent risk of physical injuries or other damages, including but not limited to heart attacks, muscle strains, pulls or tears, broken bones, shin splints, heat exhaustion, knee/lower back/foot injuries and any other illness, soreness, or injury, however caused, occurring during or after Client’s participation in physical activities. Client assumes all risks and responsibility arising from participation from physical activities. Client affirms that Client is in good physical condition and does not suffer from any physical disability that would prevent or limit participation. Client further acknowledges that such risks include, but not limited to, injuries caused by negligence of the trainer, instructor, coach or other person, defective or improperly used equipment, and over-exertion of Client, slip and fall by Client, or unknown health problem of Client. Client, on behalf of Client, his or her heirs, assigns and next of kin, waives any claims against and release

MBS CONNECTION® Owned & Operated by MBS Association, LLC (as well as any of its owners, employees, or other authorized agents, including independent contractors) from any and all liability, claims and/or causes of action that Client may have injuries or other damages of any kind, including but not limited to punitive damages, arising in participation in MBS CONNECTION® Owned & Operated by MBS Association, LLC programs and services, including, but not limited to personal training/small group training/nutritional guidelines/wellness or intensive coaching activities.

Informed Consent:

Client hereby consents to voluntarily engage in acceptable personal fitness/small group training/nutritional guidelines/wellness or intensive coaching programs and/or services. Client also gives consent to be placed in dietary counseling, stress management, health, fitness and wellness educational activities. A professional MBS CONNECTION® Owned & Operated by MBS Association, LLC fitness trainer, instructor and coach will provide leadership to direct Client’s activities, monitor Client’s performance, and otherwise evaluate Client’s effort. Client acknowledges that depending on Client’s health status; Client may or may not be required to have blood pressure and heart rate evaluated during aforementioned activities. Client understands that involvement in aforementioned programs and/or services will benefit Client’s physical fitness or general health. Client understands these aforementioned activities; Client understands if Client follows program and/or service instructions, that Client will likely improve exercise capacity and fitness level after a period of (3) three to (6) six months. Client has been informed that any and all information which is obtained in MBS CONNECTION® Owned & Operated by MBS Association, LLC programs and/or services will be treated as privileged and confidential. Consequently, any and all information will not be released or revealed to any person, to use any and all information which is not personally identifiable with Client for research and statistical purposes; so long as same does not identify Client’s person or provide facts which could lead to identification. Any information obtained, however, will be used only by MBS CONNECTION® Owned & Operated by MBS Association, LLC staff to evaluate Client’s exercise status or needs. Client also understands that during performance of activities physical touching and positioning of Client’s body may be necessary to assess muscular and bodily reactions to specific exercises, as well as to ensure Client is using proper technique and body alignment. Client expressly consents to MBS CONNECTION® Owned & Operated by MBS Association, LLC trainers, instructors and coaches to physical contact for the aforementioned reasons.

Client acknowledges that all MBS CONNECTION® Owned & Operated by MBS Association, LLC programs and services must be pre-paid. Payments of cash, checks, credit card and EFT are accepted methods of payment to MBS CONNECTION® Owned & Operated by MBS Association, LLC.

Client acknowledges that MBS CONNECTION® Owned & Operated by MBS Association, LLC training programs and/or services are non-refundable, non-transferable and expire.

Client acknowledges that MBS CONNECTION® Owned & Operated by MBS Association, LLC will charge ($35) thirty-five dollars for checks that are returned for non-sufficient funds (NSF).

Client acknowledges that MBS CONNECTION® Owned & Operated by MBS Association, LLC will charge a ($35) thirty-five-dollar late fee for all payments not cleared on agreed upon billing date.

Client acknowledges that MBS CONNECTION® Owned & Operated by MBS Association, LLC will suspend training and/or services until all payments and late fees are made in full and accounts are up to date and in good standing. Client acknowledges and agrees that account balances that are past due (30) days are subject to an additional ($50) fifty-dollar service fee charge.

Additional Provisions and Conditions:

Please initial next to each point recognizing that you fully understand MBS CONNECTION® Owned & Operated by MBS Association, LLC additional provisions and conditions.

Payment and Billing: Client has two options for payment: (1) Payment in full for all programs and/or services; or (2) Monthly payment by credit card, checking or savings account (EFT Form & Billing Agreement required) per the guidelines established on the EFT Form & Billing Agreement. Each month on the date designated on EFT Agreement the monthly payment is charged to the Client’s credit card or deducted from the Client’s checking or savings account.

Client may cancel this Agreement at any time prior to midnight of the (3rd) third business day after the date of the Enrollment Agreement is entered, excluding Saturdays, Sundays and Holidays. To cancel this Agreement, mail or hand deliver a signed and dated notice that states you, the Client, are cancelling this Agreement.

No refunds shall be made for programs and/or services purchased, except as specifically provided in the Agreement.

Client acknowledges that MBS CONNECTION® Owned & Operated by MBS Association, LLC training programs and/or services are non-refundable, non-transferable and expire.

Client acknowledges that MBS CONNECTION® Owned & Operated by MBS Association, LLC will charge ($35) thirty-five dollars for checks that are returned for non-sufficient funds (NSF).

Client acknowledges that MBS CONNECTION® Owned & Operated by MBS Association, LLC will charge a ($35) thirty-five-dollar late fee for all payments not cleared on agreed upon billing date.

Clients Right to Cancel:

The Client may not terminate or cancel this Agreement except as follows: (1) If by reasons of death or disability, Client is unable to receive MBS CONNECTION® Owned & Operated by MBS Association, LLC programs and/or services for which Client has been contracted, Client and Client’s estate shall be relieved from the obligation of making payments for programs and/or services other than those received or obligated prior to Client’s death or disability. Substantial physical disability certified by a physician, which makes it permanently impossible for the Client to use MBS CONNECTION® Owned & Operated by MBS Association, LLC programs and/or services; and (2) Client’s permanent relocation over (50) miles distance from MBS CONNECTION® Owned & Operated by MBS Association, LLC training and/or service territory in New Jersey. MBS CONNECTION® Owned & Operated by MBS Association, LLC may require proof to substantiate relocation over (50) miles of MBS CONNECTION® Owned & Operated by MBS Association, LLC service territory. Client will be refunded sum as is allocated for program and/or services Client has not yet received.

Clients Right to Hold:

Client may for a period of two weeks or longer, “put on hold” the Agreement. The request to place Agreement on hold must be submitted prior to the hold dates and must include an end date. No retroactive holds will be accepted. The following exceptions: Client is injured or sick, or Client is pregnant. In both circumstances, the return date will be mutually determined based on recovery and recuperation of the Client.

Clients Default:

Client shall be deemed in default of this Agreement upon failure to comply with any of the terms and conditions of this Agreement, including, but not limited to, the obligation to make payments on the agreed upon due date. Upon default, MBS CONNECTION® Owned & Operated by MBS Association, LLC programs shall have the right and remedies available, including termination of this Agreement and Institution of an action for all applicable damages. If MBS CONNECTION® Owned & Operated by MBS Association, LLC programs delays or refrains from exercising any rights under this Agreement, MBS CONNECTION® Owned & Operated by MBS Association, LLC programs does not waive the right to receive full and timely non-discounted payments and other charges due under this Agreement.

Enforceability:

MBS CONNECTION® Owned & Operated by MBS Association, LLC programs and Client agrees that if any provision or portion of this Agreement is declared void and unenforceable, such provision or portion of a provision shall be deemed severed from this Agreement, which shall remain in full force and effect. However, Client specifically agrees that all the terms, provisions and conditions are to be enforced and Client specifically waives any statue or other right of any type, which would invalidate the enforceability of any provision or portion of a provision of this Agreement.

Governing Law:

This Agreement shall be governed and enforced in accordance with the laws of the State of New Jersey. In the event litigation is necessary to enforce any of the terms, provisions and conditions of this Agreement, MBS CONNECTION® Owned & Operated by MBS Association, LLC programs and Client agree that the venue for such action shall exclusively be Ocean County, New Jersey.

Attorney Fees:

In the event either party finds it necessary to commence litigation or other court action to enforce the terms, provisions and conditions of this Agreement, the prevailing party in such litigation or court action shall be entitled to receive their actual attorney’s fees incurred, together with court costs, and other charges from the other party as a part of any ruling or judgment.

Entire Agreement:

This Enrollment Agreement, EFT Form, Billing Agreement and Bylaws constitute the entire and exclusive Client Agreement between the parties. Any promise, representation, understanding, oral or written, pertaining directly or indirectly to the Agreement which are not continued herein, are hereby waived.

Client:

Client hereby certifies that; Client has received a copy of Rule and Bylaws and have read and understand them.

Billing Policies

CLIENT MAY CANCEL CLIENT ENROLLMENT AGREEMENT, PAYMENT AND BILLING AGREEMENT AND EFT AGREEMENT AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD (3RD) BUSINESS DATE OF THE CLIENT ENROLLMENT AGREEMENT, PAYMENT AND BILLING AGREEMENT AND EFT AGREEMENT HAS BEEN SIGNED, EXCLUDING SATURDAY, SUNDAYS AND HOLIDAYS. TO CANCEL CLIENT ENROLLMENT AGREEMENT, PAYMENT AND BILLING AGREEMENT AND EFT AGREEMENT MAIL OR HAND DELIVER A SIGNED AND DATED NOTICE THAT STATES YOU, THE CLIENT ARE REQUESTING A CANCELATION OF CLIENT ENROLLMENT AGREEMENT, PAYMENT AND BILLING AGREEMENT AND EFT AGREEMENT.

Refunds:

No refunds shall be made for program(s) and service(s) purchased, except as specifically provided by the MBS CONNECTION® Enrollment Agreement.

PAYMENT AND BILLING:

Client has three (3) options for program(s) and service(s): 1. Payment in full for all MBS CONNECTION® program(s) and service(s); or (2) Monthly Payment by credit card, checking account, or savings account (MBS CONNECTION® EFT Agreement Form Required) per guidelines established on the MBS CONNECTION® EFT Agreement. Each month on the date designated on the MBS CONNECTION® EFT Agreement the monthly payment is charged to Client’s credit card or deducted from Client’s checking account or savings account; (3) Financing through a third party. Credit approval required by institution issuing the line of credit. For more information on financing please speak to our Enrollment Specialist.

EFT Agreement Discount:

Client understands that MBS CONNECTION® has, or may in the future, extend to Client an EFT Agreement discount that shall be offered only if the following conditions are met:

1. Client must have no outstanding balances due for any prior dates of program(s) or service(s) received by Client.

2. All payments must be prepaid in full by monthly EFT (MBS CONNECTION® EFT Agreement) required). Credit Cards, Personal or Money Orders are the only acceptable methods of payments on pre-paid month to month accounts.

3. Neither MBS CONNECTION® or MBS Association, LLC, or its agents shall be required at any time, present or future, to complete or otherwise submit, any insurance filing or billing paperwork regarding such program(s) and service(s) paid for under this Agreement.

LATE FEES AND PENALTIES:

1. In the event that Client’s payment shall not clear the applicable financial institution, e.g. a check is returned for insufficient funds (the check bounces), that the offer of a discount shall be deemed revoked, and that Client agrees to be personally responsible for payment in full, current non-discounted amount for program(s) and service(s).

2. In the event that Client’s payment shall not clear the applicable financial institution, e.g. a check is returned for insufficient funds (the check bounces), that Client will be personally responsible for the payment of late fees in the amount of fifty dollar ($50) and returned check for insufficient funds fee of thirty-six dollars ($36). Payments received thirty (30) days late will be subject to an additional penalty of fifty ($50) dollars.

3. In the event, Client requests additional receipts, invoices or client account statements, Client agrees to pay a service fee of twelve ($12) dollars for the first twenty (20) pages and an additional fifty-five (.55) cents per additional page.

4. In the event that Client breaches the MBS CONNECTION® Enrollment Agreement, Billing and Payment Agreement and/or EFT Agreement, Client is financially responsible for additional billing and paperwork fees of twenty-five ($25) dollars per hour of billing and paperwork preparation and/or legal paperwork (Client Breach of Agreement) fees of fifty ($50) dollars per hour of legal paperwork preparation.

Waiver and Release of Liability

In consideration of the risk of injury while participating in MBS CONNECTION® program(s), and consideration for the right to participate in the MBS CONNECTION® program(s), Client hereby, for themselves, their heirs executors, administrators, assigns, or personal representatives, knowingly and voluntarily enter into this waiver and release of liability and hereby waive any and all rights, claims or causes of action of any kind whatsoever arising out of Client’s participation in the MBS CONNECTION® program(s), and hereby release and forever discharge MBS CONNECTION® and MBS Association, LLC located at 72 Pine Oak Blvd, Barnegat, New Jersey 08005, their affiliates, managers, Clients, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors, and assigns, for any physical or psychological injury, including but not limited to illness, paralysis, death, damages, economical or emotional loss, that Client may suffer as a direct results of Client participation in the aforementioned MBS CONNECTION® program(s), including traveling to and from MBS CONNECTION® related to MBS CONNECTION® program(s).

CLIENT ACKNOWLEDGES THEY ARE VOLUNTARILY PARTICIPATING IN THE AFOREMENTIONED MBS CONNECTION® PROGRAM(S) AND CLIENT IS PARTICIPATING IN THE MBS CONNECTION® PROGRAM(S) ENTIRELY AT THEIR OWN RISK. CLIENT IS AWARE OF THE RISKS ASSOCIATED WITH TRAVELING TO AND FROM AS WELL AS PARTICIPATING IN THE MBS CONNECTION® PROGRAM(S), WHICH MAY INCLUDE, BUT ARE NOT LIMITED TO, PHYSICAL OR PSYCHOLOGICAL INJURY, PAIN, SUFFERING, ILLNESS, DISFIGUREMENT, TEMPORARY OR PERMANENT DISABILITY (INCLUDING PARALYSIS) ECONOMIC OR EMOTIONAL LOSS, AND DEATH. I UNDERSTAND THAT THESE INJURIES OR OUTCOMES MAY ARISE FROM CLIENT’S OWN OR OTHERS’ NEGLIGENCE, CONDITIONS RELATED TO TRAVEL, OR THE CONDITION OF THE MBS CONNECTION® LOCATION(S). NONETHELESS, CLIENT ASSUMES ALL RELATED RISKS, BOTH KNOWN OR UNKNOWN TO CLIENT, FOR CLIENT’S PARTICIPATION IN MBS CONNECTION® PROGRAM(S), INCLUDING TRAVEL TO, FROM AND DURING MBS CONNECTION® PROGRAM(S).

Client agrees to indemnify and hold harmless MBS CONNECTION® and MBS Association, LLC against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by MBS CONNECTION® and MBS Association, LLC or anyone on behalf of MBS CONNECTION® and MBS Association, LLC, including attorney’s fees and any related costs, if litigation arises pursuant to any claims made by Client or by anyone acting on my behalf. If MBS CONNECTION® and MBS Association, LLC incurs any of these types of expenses, Client agrees to reimburse MBS CONNECTION® and MBS Association, LLC.

Client acknowledges that MBS CONNECTION® and MBS Association, LLC and their directors, officers, volunteers, representatives and agents are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of MBS CONNECTION® and MBS Association, LLC.

CLIENT ACKNOWLEDGES THAT MBS CONNECTION® AND MBS ASSOCIATION, LLC PROGRAM(S) MAY INVOLVE A TEST OF A PERSON’S PHYSICAL AND MENTAL LIMITS AND MAY CARRY WITH IT THE POTENTIAL FOR DEATH, SERIOUS INJURY, AND PROPERTY LOSS. The risks may include, but are not limited to, those caused by terrain, facilities, temperature, weather, lack of hydration, condition of participants, equipment, vehicular traffic and actions of others, including but not limited to, participants, volunteers, spectators, coaches, event officials, event monitors, and/or producers of MBS CONNECTION® program(s)

The Client hereby acknowledges that the following has been explained to them and they fully understand all the information and associated risks for participation in prescribed exercise program.

The Client acknowledges that MBS CONNECTION® trainer(s), coach(es) and representative(s) (including independent contractors) are not physicians and are not trained to provide medical diagnosis, medical treatment, psychotherapy or any other type of medical advice.

The Client acknowledges that MBS CONNECTION® trainer(s), coach(es) and representative(s) (including independent contractors) may suggest an exercise program as part of a lifestyle management plan. Client acknowledges these activities involve inherit risk of physical injuries or other damages, including, but not limited to, heart attacks, muscle strains, pulls or tears, broken bones. Shin splits, heat exhaustion, knee/lower back/ foot injuries and any other illness, soreness, or injury, however caused, during or after Client’s participation.

The Client acknowledges that they fully understand MBS CONNECTION® does not guarantee either good or bad result(s) from exercise prescription program. The Client acknowledges that weight training, aerobic classes, group fitness and any other sports are an extreme test to one’s mental and physical limits. Extreme tests of this nature carry with them the potential for damage or loss of property and/or serious injury and death.

The Client acknowledges that they entered into this agreement freely, without force or coercion and they can stop participation at any time for any reason.

The Client acknowledges the importance of providing accurate and detailed information regarding their medical history and lifestyle. The Client understands the importance of participating in the health screening process and/or clinical testing that may be required.

CLIENT ACKNOWLEDGE THAT CLIENTS HAS CAREFULLY READ THIS “WAIVER AND RELEASE” AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. CLIENT EXPRESSLY AGREES TO RELEASE AND DISCHARGE MBS CONNECTION® AND MBS ASSOCIATION, LLC AND ALL OF ITS AFFILIATES, MANAGERS, CLIENTS, AGENTS, ATTORNEYS, STAFF, VOLUNTEERS, HEIRS, REPRESENTATIVES, PREDECESSORS, SUCCESSORS, AND ASSIGNS, FROM ANY AND ALL CLAIMS OR CAUSES OF ACTION AND CLIENT AGREES TO VOLUNTARILY GIVES UP OR WAIVE ANY RIGHT THAT CLIENT OTHERWISE HAVE TO BRING A LEGAL ACTION AGAINST MBS CONNECTION® AND MBS ASSOCIATION, LLC FOR PERSONAL INJURY OR PROPERTY DAMAGE.

To the extent that the statue or case law does not prohibit release for negligence, this release is also for negligence on the part of MBS CONNECTION® and MBS Association, LLC, its agents, and employees.

In the event that Client should require medical care or treatment, Client agrees to be financially responsible for any cost incurred as a result of such treatment. Client is aware and understands that Client should carry their own health insurance.

In the event that any damage to equipment or facilities occurs as a result of Client’s or

Client’s family’s willful actions, neglect or reckless, Client acknowledges and agrees to be held liable to any and all costs associated with any actions of neglect or recklessness.

COACHING DISCLOSURE STATEMENT & AGREEMENT

Welcome! This document contains important information about my professional services and business policies. It is rather long because it covers a wide range of possible situations, many of which will not apply to you. Still, it provides a framework for understanding the services you are considering. Please read it carefully and note any questions you might have. We can discuss them at our next meeting. If you decide you would like to use my services and sign this document, it will represent an agreement between us.

WHAT IS MBS CONNECTION® COACHING?

The non-profit International Coach Federation (http://www.coachfederation.org), defines coaching as “as partnering with clients in a thought-provoking and creative process that inspires them to maximize their personal and professional potential.” My approach to “MBS CONNECTION® coaching” is an ongoing professional relationship that helps people produce extraordinary results in their lives, careers, businesses or organizations. Through the process of coaching, clients deepen their learning, improve their performance, and enhance their quality of life. In each meeting, the client chooses the focus of conversation, while the coach listens and contributes observations and questions. This interaction creates clarity and moves the client into action. Coaching accelerates the client’s progress by providing greater focus and awareness of choice. Coaching concentrates on where clients are now and what they are willing to do to get where they want to be in the future. Coaches recognize that results are a matter of the client’s intentions, choices and actions, supported by the coach’s efforts and application of the coaching process. You can expect that I, your Coach, will be honest and direct, asking straightforward questions and using challenging techniques to help you move forward. You are expected to evaluate your own progress; and, if the coaching is not working as you wish, you should immediately inform me, your Coach, so that we can both take steps to correct the problem. As with any human endeavor, coaching can involve feelings of discomfort and frustration which may accompany the process of change. Coaching does not offer any guarantee of success.

WHAT ARE THE LIMITATIONS OF MBS CONNECTION® COACHING?

MBS CONNECTION® coaching is not psychotherapy, nor is it a substitute for the diagnosis and/or treatment of mental health conditions by a psychologist, psychiatrist, or other licensed mental health professional. If you have a diagnosed mental disorder or a condition that should be evaluated by a licensed mental health professional, my services should be used only in conjunction with your obtaining that care. I do not diagnose mental health disorders, nor am I trained or licensed to do so. MBS CONNECTION® coaching attempts to help you optimize your overall vitality and mental well-being, but it is not to be used instead of appropriate care from a licensed mental health professional.

The following nine differences between psychotherapy and MBS CONNECTION® Coaching are important for you to understand prior to engaging my services:

1. Psychotherapists can provide a diagnosis based on the DSM (the American Psychiatric Association’s Diagnostic and Statistical Manual). A primary focus of psychotherapy is the identification and diagnosis of mental disorders. Coaching does not diagnose.

2. Psychotherapy can provide diagnosis independent of the client's self-assessment. This function is recognized by third parties such as the courts and insurance carriers, which often call up on psychotherapists to make diagnoses independent of the client's self-assessment. Coaching, by way of contrast, relies on the client's self-assessment.

3. Psychotherapy can use its diagnoses to treat clinical disorders. Coaching makes no claims of efficacy in treating clinical disorders.

4. Psychotherapy is often reimbursable by health insurance since diagnosis and treatment is recognized as being part of health care. Coaching is not usually reimbursable since it does not involve diagnosis or treatment.

5. Goals in psychotherapy may be set by the therapist after diagnosis. Goals in coaching are typically self-identified by the client.

6. Psychotherapy goals typically involve treatment of a mental disorder by the therapist. Coaching goals typically focus on quality of life.

7. Psychotherapy typically involves recognized power differentials between client and therapist. This vulnerability of clients gives psychotherapists legal and ethical responsibilities. Coaching is in the nature of a supportive peer-to-peer relationship, with the results evaluated by the client.

8. Psychotherapy may be provided by primary caregivers such as hospitals and may be considered an aspect of primary care. Coaching is not associated with primary care.

9. Coaches are required to refer clients to psychotherapists or psychiatrists if the client's problem is outside their scope of practice.

Psychotherapy is a health care service. Its primary focus is to identify, diagnose, and treat nervous and mental disorders. The goals include alleviating symptoms, understanding the underlying personality dynamics which create symptoms, changing the dysfunctional behaviors which are the result of these disorders, and helping patients to cope with their psychological problems. While psychotherapy may be reimbursable through health insurance policies, coaching services, at present, are not. It is understood and agreed to by The Client and The Coach that if either of us recognizes that you, The Client, have a problem that would benefit from psychotherapy, I, The Coach, may refer or direct you to appropriate resources in addition to or in lieu of coaching. In some situations, as a condition of my continuance as your Coach, I may insist that you enter psychotherapy and that I have your consent to discuss matters which concern you with your psychotherapist. It is further understood that, as The Coach, I am not obligated to provide you, The Client, with psychotherapy services.

MEETINGS

I generally schedule one appointment of sixty (60) minutes duration per week at a time we agree upon. Sessions may also, by prior agreement, be longer, shorter, more frequent, or less frequent.

CALL AND VIDEOCALL PROCEDURE FOR MEETINGS

If the Client opts to attend sessions by phone, The Client will call The Coach at the pre-arranged time and telephone number as scheduled, and The Client pays the telephone charges for the call. For group Lifestyle Coaching calls and classes, The Coach will pay for the teleconference line, and The Clients will pay for the call into the conference line.

SESSION TIME

Lifestyle Coaching is scheduled at the mutual convenience of The Coach and The Client. The day and time for the next session will be scheduled at the close of each Lifestyle Coaching session.

CANCELLATIONS

For individual Lifestyle Coaching clients, you must give forty-eight (48) hours prior notice if you need to cancel or change the time of an appointment, otherwise you will be charged for the session in full. The Coach will make reasonable efforts to reschedule sessions which are cancelled in a timely manner.

PROFESSIONAL RECORDS

I keep brief records on each session, primarily noting the date of the session, the topics discussed, the interventions used, and progress or obstacles observed as they relate to your goals in working with me. You are welcome to request, in writing, that I make available to other health care providers a copy of your file. I maintain your records in a secure location that cannot be accessed by anyone else. I will maintain your records for at least five years after our last contact, after which time I may securely dispose of them.

CONFIDENTIALITY

With the exception of special situations described below, I will keep our work together confidential. I cannot and will not tell anyone else what you have told me, or even that you are using my services without your prior written permission. You may direct me to share information with whomever you chose, and you can change your mind and revoke that permission at any time. You may request anyone you wish to attend a session with you. If I transmit information about you electronically (for example, sending bills or faxing information), it will be done with special safeguards to insure confidentiality. If you elect to communicate with me by email at some point in our work together, please be aware that email is not completely confidential. All emails are retained in the logs of your or my internet service provider. While under normal circumstances no one looks at these logs, they are, in theory, available to be read by the system administrators of the internet service provider. Any email I receive from you, and any responses that I send to you, will be kept as a part of your treatment record.

Following are seven exceptions to confidentiality:

1. There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a client’s treatment. For example, if I believe that a child, an elderly person, or a disabled person is being abused, I must file a report with the appropriate state or local agency.

2. If I believe that a client is threatening serious bodily harm to another, I am required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the client.

3. If I believe that you are in imminent danger of harming yourself, I may legally break confidentiality and contact the police, a local crisis team, or a family Client or other intimates.

4. If you tell me of the behavior of another named health or mental health care provider which suggests that this person has either (1) engaged in sexual contact with a patient, including yourself, or (2) is impaired from practice in some manner due to cognitive, emotional, behavioral, or health problems, then the law requires me to report this to the practitioner’s state licensing board. I would inform you before taking this step. If you are my client and a health care provider, however, your confidentiality remains protected under the law from this kind of reporting.

5. In certain legal proceedings, particularly those involving child custody or those in which your emotional condition or treatment is an important issue, a judge may order my testimony. Confidentiality is not protected when a judge makes such an order or in certain other legal procedures. Consult with an attorney if you are involved in a legal situation where confidentiality may be at issue.

6. If am consulted by your spouse, partner, or another Client of your family, we will in advance establish the limits of confidentiality. It generally limits a practitioner’s effectiveness when required to keep secrets, so my policy in most circumstances is that what you say and what we do can be shared with other family Clients. If this is what we establish, do not tell me anything you wish kept secret from other intimates I am working with. If confidential information is a concern, it is better for each family Client to work with a different practitioner.

7. I may occasionally find it helpful to consult other professionals about a client. During a consultation, I make every effort to avoid revealing the identity of the client. The consultant is also bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, please discuss with me any questions or concerns that you may have. I will be happy to explore these issues with you, but formal legal advice may be needed from an attorney because the laws governing confidentiality can be quite complex.

MINORS

If you are under eighteen years of age, please be aware that the law may provide your parents or legal guardians the right to examine my records of our work together. It is my policy to request a written agreement from parents to waive their right to access your records. If they agree, I will provide them only with general information about our work together unless I feel there is a high risk that you will seriously harm yourself or someone else. In this case, I will notify them of my concern. Before giving them any information, I will discuss the matter with you, if possible, and do my best to handle any objections you may have with what I am prepared to discuss.

PROFESSIONAL FEES

My fee for a sixty (60) minute session is $95. If we decide to meet for a longer session or a shorter session, I will bill you prorated on this hourly fee. In addition to scheduled appointments, I also pro-rate the hourly fee for other professional services you may request. Other services might include emergency telephone conversations lasting longer than 10 minutes, listening to lengthy voice mail messages, reading and responding to e-mails other than for routine business, attendance at meetings with other professionals you have authorized, and the preparation of requested records or treatment summaries. If you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party. Because of the difficulty of legal involvement, I charge $175 per hour for preparation and attendance at any legal proceeding.

BILLING AND PAYMENTS

You will be expected to pay for each session at the time it is held unless we agree otherwise. Payment schedules for other professional services will be agreed to when they are requested.

Once an appointment is scheduled, you will be expected to pay for it unless you provide 48 hours advance notice of cancellation. If you are late, we will still end on time and not run over into the next person's session. If you miss a session without canceling, or cancel with less than twenty-four hours’ notice, you must pay for that session by the time of our next meeting unless we both agree that you were unable to attend due to circumstances beyond your control. In circumstances of unusual financial hardship, I may be willing to negotiate a payment installment plan.

If that is done and your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, its costs will be included in the claim. In most collection situations, the only information released is the client’s name, contact information, dates and type of services provided, and the amount due.

CONTACTING ME

I am often with a client or otherwise not immediately available by telephone. When I am unavailable, you will reach my voice mail. I monitor it frequently and will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If it will be difficult to reach you, please inform me of sometimes when you will be available. If you are unable to reach me and feel that you can’t wait for me to return your call, contact your family physician or, if you are experiencing a medical emergency, call 911 or go to the nearest hospital emergency room.

OTHER ASPECTS OF OUR RELATIONSHIP

You have the right to ask me questions about anything that happens in our work together. I'm always willing to discuss how and why I've decided to do what I'm doing, and to look at alternatives that might work better. You can feel free to ask me to try something that you think will be helpful. You can ask me about my training for working with your concerns and can request that I refer you to someone else if you decide I'm not the right practitioner for you. You are free to terminate our work together at any time.

I never in engage in sexual intimacies with clients or former clients and generally avoid social and business relationships. Beyond the legal and ethical considerations, our work together will be most effective when kept free from possible outside entanglements.

You normally will be the one who decides therapy will end, but there are three exceptions to this. (1) If I determine that I am unable, for any reason, to provide you with the services you are requesting at a high professional standard, I will inform you of this decision and refer you to another therapist who may better meet your needs. (2) If you verbally or physically threaten or harass me, my office, or my family, I reserve the right to terminate you from treatment immediately and unilaterally. (3) I reserve the right to refuse or terminate a session if you or anyone in the session is suspected of being under the influence of a mood-altering substance. You will be responsible and charged for full payment of the normal fee.

If you are involved in legal proceedings based on your having been traumatized, please understand that through our work together, traumatic memories may lose their emotional charge, and this could adversely affect your ability to provide legal testimony that carries the same impact as prior to treatment.

I am away from the office several times each year for vacations or to attend professional meetings. I will make every effort to tell you well in advance of any anticipated lengthy absences and to discuss other options for continuing to work toward your goals during my absence.

COMPLAINTS

If you are unhappy with the way our work together is proceeding, I hope you will talk about it with me so that I can respond to your concerns directly. I will take such concerns seriously and meet them with care and respect. You are also free to discuss any complaints about me with anyone you wish. You do not have any responsibility to maintain confidentiality about what I say or do. You are the person who has the right to decide what you want kept confidential. If you believe that I've been unwilling to listen and respond, or that I have behaved unethically, you can register a complaint about my behavior with the coaching organization that certifies me [[include exact name, address, phone, and website as appropriate.]].

Your signature below indicates that you have read the information in this document, understand it fully, have discussed any questions or matters of concern with me and/or others, and agree to abide by its terms during our professional relationship.

Informed Consent for Fitness Evaluation

Additional Information

The Graded Exercise Test

The test is performed on a cycle ergometer or motor driven treadmill. The workload will increase every few minutes until you reach exhaustion or until other symptoms dictate test should be terminated. You have the right to stop the test at any time because of fatigue or discomfort.

The following are examples of symptoms that dictate a test should be terminated:

Absolute Indications

1. Suspicion of myocardial infraction (heart attack) or acute myocardial infraction

2. Onset of moderate to severe angina (chest pain)

3. Drop in systolic blood pressure (SBP) below standing resting pressure or drop in SBP while increasing workload accompanied by signs or symptoms

4. Signs of poor perfusion (circulation of blood flow), including pallor (pale appearance to skin), cyanosis (bluish discoloration), or cold and clammy skin

5. Shortness of breath

6. Central Nervous System (CNS) symptoms

a. Ataxia (failure of muscular coordination), vertigo (illusion of dizzying movement), visual or gait (pattern of walking or running) problems, confusion, serious arrythmias (abnormal heart rhythms)

b. Second/third degree Atrioventricular (AV) block, atrial fibrillation with fast ventricular response, increasing premature ventricular contractions or sustained ventricular tachycardia

7. Technical inability to monitor ECG (Electrocardiography)

8. Client’s request to stop

Relative Indications

1. Any chest pain that is increasing

2. Physical or verbal manifestations of shortness of breath or severe fatigue

3. Wheezing

4. Leg cramps or intermittent claudication (grade 3 on a 4-point scale)

5. Hypertensive response (SBP >260mm Hg; DBP> mm Hg)

6. Pronounced ECG changes from baseline

a. <2mm of horizontal or down sloping ST-segment depression, or > mm of ST- segment elevation (except VR)

7. Exercise induced bundle branch block that cannot be distinguished from ventricular tachycardia

8. Less serious arrhythmias (abnormal heart rhythms) such as supraventricular tachycardia

Muscle Fitness Testing

Test is performed by you lifting weights for a number of repetitions using dumbbells, barbells, or exercise machines. The test will abide in determining the endurance and strength of major muscle groups.

Flexibility and Balance Training

During flexibility evaluation you will perform a number of tests to measure the range of motion in your joints.

Balance testing requires you maintain certain stances and/or the distance you are able to reach while maintain your balance.

Body Composition Testing

Skinfold Method-Indirect measurement of the thickness of subcutaneous adipose tissue.

Bioelectrical Impendence Analysis-A rapid noninvasive method where low level electrical current is passing through your body and the opposition of flow of current is analyzed.

Anthropometric Methods-Using a combination of weight, height, skeletal diameters and circumferences to estimate total body density, relative body fat and fat free mass.

Field Test

1. Distance Run

2. 9- or 12-minute run

3. 1.5-mile run/walk test

4. 1.0-mile jogging

5. Walking and Step Tests-will be used when a cycle ergometer and treadmill are not well suited for measuring cardiorespiratory fitness.

Risks and Discomforts

During submaximal and/or maximal graded exercise testing certain changes can take place. Changes may include abnormal blood pressure responses, fainting irregularities in heart beat and/or heart attack. MBS CONNECTION® will make every effort to minimize these occurrences, and MBS CONNECTION® are trained to deal with these situations if they occur. There is a small risk of pulling a muscle or spraining a ligament during muscle fitness and flexibility testing. You may also experience muscle soreness 24 to 48 hours after testing. Performing warm up exercises prior to testing can minimize pulled muscles, sprained ligaments and muscle soreness.

Expected Benefits from Exercise Testing

The tests prescribed allow MBS CONNECTION® to assess your physical working capacity to appraise your physical fitness status. The results are then used to determine and prescribe a sound and safe individualized exercise program. All records are kept confidential unless you give me written consent to release this information.

Inquiries

MBS CONNECTION® encourages you to ask questions and/or request any additional information regarding procedures used in physical fitness tests and exercise prescription program(s).

Freedom of Consent

Your permission to perform these physical fitness tests is voluntary. You are free to stop these tests at any time, if you should desire to do so.

The undersigned acknowledges that they have read the form carefully and fully understand the test procedures. The undersigned acknowledges the risks and the potential discomforts associated with tests. The undersigned acknowledges that the risks have been explained to them and they have been given the opportunity ask questions that have been answered to their satisfaction.

The undersigned consents to participate in the health screening process and exercise testing.

Informed Consent Program(s) & Service(s)

Additional Information

This Informed Consent is made between MBS CONNECTION® and _____________________ (herein after client). (client print name)

Client understands that MBS CONNECTION® fitness training program(s), coaching service(s), nutraceutical(s), and nutrition program(s) are tailored to meet the goals and objectives agreed upon by

MBS CONNECTION® and the Client. Client understands that Partner Training, Small Group Training, and MBS Group X are tailored to meet the goals and objectives of multiple individuals who may or may not have similar goals and objectives to Client.

Description of Exercise Program(s): Client understands that exercise program(s) will involve participation in a number of fitness activities. These activities will vary depending upon the objectives that the Client and MBS CONNECTION® establish, but will probably include: (1) aerobic activities including, but not limited to, use of treadmills, stationary bikes, step machines, rowing machines, bike/run trail; (2)muscular endurance and strength building exercises including, but not limited to, the use of free weights, weight machines, calisthenics, and exercise apparatus; (3) other activities selected by Client and MBS CONNECTION®; and (4) selected physical fitness and body composition tests.

Description of Potential Risk(s): Client understands that no exercise program is without inherent risks regardless of the care taken by the fitness trainer, instructor and/or coach. Client acknowledges that when participating in any exercises, particularly those that include cardiovascular stress, there is a slight chance of serious injury (e.g., heart attack, stroke, or other cardiovascular accidents) or catastrophic incident (e.g., death, paralysis). Client acknowledges and agrees that engaging in muscular endurance, strength building, and other fitness activities sometimes results in minor injuries (e.g., bruises, musculoskeletal strains and sprains), and rarely), less frequent, more serious injuries (e.g., muscle tears, herniated discs, torn rotator cuffs), and rarely, catastrophic injury (e.g., death, paralysis).

Description of Potential Benefit(s): Client understands that a regular exercise program has been shown to have definite benefits to general health and well-being. Client acknowledges that some benefits may include loss of weight, reduction in body fat, improvement of blood lipids, lowering of blood pressure, improvement of cardiovascular function, reduction in the risk of heart disease, improved strength and muscular endurance, improved posture, and improved flexibility.

Client Responsibility: Client understands that it is the Client’s responsibility to (1) fully disclose any health issues or medications that are relevant to participation in strenuous exercise program; (2) cease exercise and report promptly any unusual feelings (e.g., chest discomfort, nausea, difficulty breathing, and apparent injury) during exercise program, and (3) clear Client participation with Client’s physician.

In consideration of my desire to engage in an exercise program at the MBS CONNECTION®. Client understands and agrees to the following:

1. Participation by me in this activity is entirely voluntary.

2. Client understands the potential risks involved in the exercise program and believes that the potential benefits outweigh the risks.

3. Client gives consent to certain physical touching that may be necessary to ensure proper technique and body alignment.

4. Before Client engages in any activity, Client will complete health history form as well as an evaluation with a Physical Therapist or Athletic Trainer to determine Client risk of participating in exercise as well as areas that need to be addressed in my exercise program. If the health history, physical activity readiness questionnaire or evaluation indicates that Client should see physician before exercising, Client will do that.

5. Client understands that the possibility exists that certain changes may occur during exercise. They may include muscular stains, sprains, and delayed onset muscle soreness, abnormal blood pressure, fainting, disturbances of heart rhythm, and very rare instances of heart attack.

6. Client understands that Client can minimize the risk of adverse changes occurring during exercise by adhering to the exercise guidelines which discuss the importance of warming up and cooling down and exercising at a moderate level at least 3 times per week.

7. Client understands that a program of regular exercise for the heart, lungs, muscles and joints, has many benefits associated with it. These may include a decrease in body fat, improvement in blood fats and blood pressure, improvement in physiological function, increased strength, decreased chance of injury and decrease in heart disease.

8. Client understands that the achievement of health and fitness objectives cannot be guaranteed

9. Client has been able to ask questions regarding any concerns Client might have and has had those questions answered to Client’s satisfaction.

10. Client has had a voice in planning and approving the activities selected for the Client’s exercise program(s).

11. Client has been advised to cease activity immediately if Client experiences unusual discomfort and feels the need to stop.

12. Client is in good physical condition, has no impairment which might prevent Client participation in such activities, and has been advised to consult with a physician prior to beginning this program.

I, the undersigned, waive and release and agree to hold harmless and indemnify the MBS CONNECTION®, its employees, agents, officers and directors against any and all claims any way connected with my participation in an exercise program. This agreement is binding on my heirs, executors, administrators and assigns.