The Daniel Plan Registration & Participation Waiver
Wednesdays / Jan 15th - Feb 19th / 7:30-8:30 pm

Chesapeake Community of Hope
1009 Scenic Pkwy, suite J, Chesapeake, VA 23323

757.436.0079 / office@ccohchurch.com / ccohchurch.com
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Email *
First Name *
Last Name *
Phone Number *
Address *
Disclaimers
The Client understands that the role of the Health Coach is not to prescribe or assess micro- and macronutrient levels; provide health care, medical or nutrition therapy services; or to diagnose, treat or cure any disease, condition or other physical or mental ailment of the human body. Rather, the Coach is a mentor and guide who has been trained in holistic health coaching to help clients reach their own health goals by helping clients devise and implement positive, sustainable lifestyle changes. The Client understands that the Coach is not acting in the capacity of a doctor, licensed dietician-nutritionist, psychologist or other licensed or registered professional, and that any advice given by the Coach is not meant to take the place of advice by these professionals. If the Client is under the care of a health care professional or currently uses prescription medications, the Client should discuss any dietary changes or potential dietary supplements use with his or her doctor, and should not discontinue any prescription medications without first consulting his or her doctor.  
The Client has chosen to work with the Coach and understands that the information received should not be seen as medical or nursing advice and is not meant to take the place of seeing licensed health professionals.
I have read and accept the above Disclaimers *
Personal Responsibility and Release of Health Care Related Claims
The Client acknowledges that the Client takes full responsibility for the Client’s life and well-being, as well as the lives and well-being of the Client’s family and children (where applicable), and all decisions made during and after this program.  
The Client expressly assumes the risks of the Program, including the risks of trying new foods or supplements, and the risks inherent in making lifestyle changes. The Client releases the Coach from any and all liability, damages, causes of action, allegations, suits, sums of money, claims and demands whatsoever, in law or equity, which the Client ever had, now has or will have in the future against the Coach, arising from the Client’s past or future participation in, or otherwise with respect to, the Program, unless arising from the gross negligence of the Coach.
I have read and accept the above Personal Responsibility and Release of Health Care Related Claims *
Confidentiality Agreement
The Coach will keep the Client’s information private, and will not share the Client’s information to any third party unless compelled to by law.

This agreement shall be construed according to the laws of the State of Virginia. In the event that any provision of this Agreement is deemed unenforceable, the remaining portions of the Agreement shall be severed and remain in full force.
I have read and accept the above Confidentiality Agreement *
By typing my name, I am registering for The Daniel Plan at CCOH *
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