Address
899 Skokie Blvd #304
Northbrook, IL 60062
Phone
Fax
(847) 564-8755
899 Skokie Blvd #304
Northbrook, IL 60062
(847) 564-8755
As part of an Optimal Functioning skills-building coaching program, Dr. Ben Allen offers his 24 years of martial arts experience and his extensive training and education in active wellness exercises and strategies into a unique way to help clients, this in addition to the general services of his psychology and coaching practices. Dr. Allen’s training is only to current and existing clients in the course of a session if requested. Dr. Allen does not teach direct self-defense skills for close range fighting, nor is there any physical person-to-person contact. Dr. Allen does not promote using any skills learned by him for fighting. This model is different from the typical community martial arts programs that meet regularly, and offer structured training and a ranking system. Dr. Allen’s Kung Fu program is for building true mental and physical skills, and compliments his biofeedback and self-regulation training. Dr. Allen can recommend various martial arts programs in the community for those who wish to train further, and discuss what to look for in training, and in training wellness products based on a client’s needs.
Understanding of Limitations of Training, Rules, and Promise Not To Sue:
As a condition of my participation in Kung Fu Room Coaching and Skills Building, I understand that Dr. Ben Allen holds a 3rd degree black belt certificate in Northern Shaolin Eagle Claw Kung Fu, and currently trains under 6th Degree Black Belt in Northern Shaolin Eagle Claw Kung Fu Sifu Roger Sultzman, and additional fighting and self-defense skills under 4th Degree Black Belt in Northern Shaolin Eagle Claw and 3rd Degree in Praying Mantis Kung Fu Sifu Jimmy Ortiz. Dr. Allen does not make any claims that he is a martial arts master beyond his skills. He has been trained extensively to teach basic martial arts skills and concepts, and in his private practice he does not represent any style or school. Dr. Allen has 26 solid years of training and experience in martial arts.
I understand that I am not being trained or prepared for any actual fighting, kung fu or otherwise. Dr. Ben Allen will not initiate any direct physical contact toward me at any time, but he will hold focus mitts and a large holding targets for me to strike and kick, block, and make contact with wooden or padded weapons.
I enter the Kung Fu Room and participate in the Kung Fu skills coaching entirely of my own free will, and entirely at my own risk. Although Dr. Ben Allen will not initiate any direct contact toward me at any time, I understand that I will be engaging in physical activity as part of my participation. I understand that no type of physical activity is 100% safe, and that any type of physical exertion can result in injury to person or property. By signing this document, I am stating that I possess the requisite good health and overall physical ability to safely engage in the following types of physical activities (moves making impact – strikes & kicks & blocks, vigorous body movements and stances, strength-building exercises, use of basic Kung Fu weapons, shadow boxing, stretching, and cardiovascular conditioning, as well as Chi Gung Breathing and movement). If I have any doubts or concerns whatsoever about my health and physical ability to engage in the above activities, I will discuss those doubts and concerns with Dr. Ben Allen as well as with my health care provider before signing this document. I understand that I am solely responsible for any medical, health, or personal injury costs relating to my participation in the Kung Fu Room Skills Coaching Services.
I have read the Kung Fu Room explanation and information of services sheet, and I know that prior to me signing this contract, I have the right to see the Kung Fu Room and be exposed to the full spectrum of tools and product examples of training opportunities. I have read and understand the Rules of the Kung Fu Room document, and I promise to abide by them. I understand that my reading, understanding, and abiding by the Rules of the Kung Fu Room will decrease, but not eliminate, the risk of injury to me or my property.
In the case of injury to me or my property, I promise not to sue Dr. Ben Allen or Mind for Health Resources, Ltd., or any one associated with them, for any reason or any way connected with my participation in Kung Fu Room skills coaching. I understand that nothing in this document can waive my right to sue in cases of gross negligence or wanton misconduct of Dr. Ben Allen.
I have had the chance to discuss all questions and concerns regarding the Kung Fu Room and Services, have had my questions answered, and believe I understand what is being offered. Therefore, I agree to play an active role in using the Kung Fu Room and services, and I give Dr. Ben Allen permission to train and coach me in basic martial arts skills, as shown by my signature below.
Signature of client (or parent/guardian or representative of child)
Signature of minor under 18
Signature of Dr. Ben Allen
Date
Date
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