Release form for frequency treatment

[Richard Di Nucci]

Release Form for Rife Frequency Treatment – Revision 5

I, ______________________________ fully acknowledge the implications of the following seven (7) paragraphs listed below; further, I fully understand, acknowledge, and accept the potential consequences either expressed or implied by these statements below.

1. I have received an experimental Rife device, Model # ______________________ (hereinafter referred to as “device”) on temporary loan, for a period of two weeks, from ____________________________(name of device owner) on the date shown below. Further, while in my possession, I am responsible for the safe-keeping of this device.

2. I have been trained in the specific procedures that are to be used in connection with the safe operation of this experimental device, and I have been trained in specific safety precautions that are to be followed, before, during and after the use of this device.

3. This device will be used by me only, and I agree that I will not allow other persons to use it while it is in my possession.

4. Use of this device is for education and entertainment purposes only.

5. The duration when this device is in my possession is specified in Paragraph # 1 as two (2) weeks; however, the device owner may grant me additional time to use this device. Further, there may be occasions when the device owner may require this device while it is in my possession. In that event, the device owner will provide a 24 hour "advanced notice" to me, that the device must be returned on the following day.

6. The device owner is receiving no compensation of any kind for allowing me to borrow this device.

7. The Temporary User of this device has been advised to seek the counsel of a licensed medical practitioner if they believe that they are ill.


Signed below by the Owner and the Temporary User of this Device:


_______________________________________
Temporary User of Device Date

_______________________________________
Owner of This Device Date


Comment to Forum Members: Feel free to use this template, or modify it in whatever way you wish; if there is another template that has been used and found to be acceptable by Rifers, please provide info about it, or a link to it within this thread.