SMOKING CESSATION VIRTUAL EXPERIENCE CONSENT AND RELEASE AGREEMENT
PLEASE READ THIS AGREEMENT CAREFULLY. IF YOU HAVE ANY QUESTIONS, PLEASE DO NOT HESITATE TO ASK.
I understand that I am being offered the opportunity to participate in a virtual reality experience designed to help me quit smoking in which I will view and experience virtually enhanced images and sounds by utilizing a virtual reality headset (the “Experience”). By signing below I acknowledge that I have read this Agreement prior to signing it and I understand its contents.
1. Health and Safety. I acknowledge and agree that by participating in the Experience, it is possible to experience adverse side effects, including symptoms similar to motion sickness; dizziness; fatigue; disorientation; eye strain; impaired hand-eye coordination; altered, blurred, or double vision or other visual abnormalities; loss of awareness; impaired balance; nausea; lightheadedness; and discomfort or pain in the head or eyes. Seizures: I understand that some people (about 1 in 4000) may have severe dizziness, seizures, eye or muscle twitching or blackouts triggered by light flashes or patterns while experiencing virtual reality, even if they have no history of seizures or epilepsy. I acknowledge that I should not participate in the Experience if I am: tired; need sleep; under the influence of alcohol or drugs; hung-over; have digestive problems; under emotional stress or anxiety; or suffering from symptoms cold, flu, headaches, migraines, or earaches, as this can increase my susceptibility to adverse symptoms. I further acknowledge that I should see a doctor before participating in the Experience if I am pregnant, elderly, have a pacemaker or other implanted medical device, have pre- existing binocular vision abnormalities or psychiatric disorders, have a history of seizures or epilepsy, or suffer from a heart condition or other serious medical condition. By participating in the Experience, I represent that I am in good physical and mental health.
2. Not Medical Advice. I understand that any information or advice provided in connection with the Experience is not meant to be medical advice and that I will communicate with my physician or other health care professional before making any lifestyle or behavior changes that may affect my medical plan of care as established by my physician or other health care professional and before discontinuing any prescription medications.
4. Release. I acknowledge and agree that by participating in the Experience, I am aware of the risks associated with the Experience and am participating in the Experience at my own risk. To the maximum extent permitted by applicable law, I hereby waive any and all rights, claims or causes of action of any kind whatsoever arising out of my participation in the Experience, and do hereby release, indemnify and forever discharge, and covenant not to sue, BehaVR LLC and its owners, co-venturers, partners, officers, directors, employees, agents, attorneys, affiliates, successors and assigns, from and against any and all liability for any harm, injury, damage, claims, demands, actions, causes of action, costs, and expenses of any nature that I or any of my assigns, heirs, next of kin, spouse or legal representatives may have or that may hereafter accrue to me or my assigns, heirs, next of kin, spouse or legal representatives, arising out of or related to any loss, damage, or injury, including but not limited to personal injury or death, that may be sustained by me as a result of my participation in the Experience or any advice or instruction provided in connection therewith.
5. NO WARRANTIES. I ACKNOWLEDGE THAT NEITHER BEHAVR LLC NOR ANY EMPLOYEE, AGENT OR CONTRACTOR OF BEHAVR LLC HAS MADE ANY WARRANTIES WHATSOEVER WITH RESPECT TO EQUIPMENT OR SERVICES WHICH ARE FURNISHED IN CONNECTION WITH THE EXPERIENCE, AND THAT BEHAVR LLC EXPRESSLY DISCLAIMS ALL REPRESENTATIONS, WARRANTIES AND CONDITIONS (EXPRESS OR IMPLIED, ORAL OR WRITTEN), INCLUDING ANY IMPLIED WARRANTIES OF FITNESS FOR A PARTICULAR PURPOSE, FREEDOM FROM DEFECTS, AND NON-INFRINGEMENT. I FURTHER ACKNOWLEDGE THAT BEHAVR LLC MAKES NO REPRESENTATION, CLAIM OR GUARANTEE REGARDING ANY PARTICULAR RESULTS OR OUTCOME FROM PARTICIPATING IN THE EXPERIENCE.
By signing below, I certify that I have read this Agreement and consent to its terms.
Participant’s Signature: _____________________ Date: _____________