Pathways Core Training, Inc. In Person CHECK IN FORM

Full Name

First NameLast Name

Birth Date:

Date

E-mail

example@example.com

Cell Number

Format: (000) 000-0000.

Have you ever attended our Core Training?

If so, what is your Class #?

Who referred you to Pathways (a.k.a. your Sponsor - the person who convinced you to go)

First NameLast Name

Relationship to this person:

What is sponsor E-mail address?

example@example.com

Sponsor Cell Number

Format: (000) 000-0000.

Sponsor Mailing Address:

Street Address

Suite #, Apt #

CityState / Province

Postal / Zip Code

I understand I will be required to respect and follow any current required safety measures as requested by Pathways Core Training, Inc., the hotel staff and the trainers. There may be changes in these requirements. Please review and complete the COVID waiver. We will notify you if there are any significant changes between now and 2 days prior to your training.

Initials

To my knowledge, the information I have given is accurate:

Signature

Date

This Acknowledgement and Release ("Release"), executed on

Date

is between (Participant):

First NameLast Name

of (Participant's Address):

Street Address

CityState / Province

Postal / Zip Code

And Pathways Core Training Inc. (“Pathways”). For purposes of this Release, “Pathways Training Programs” means the collective and individual trainings, seminars, programs commonly called, The Weekend, The Walk, Partners, P1, P2, P3, and Empowered Parenting, Teen Family Camp, Step Beyond, and any other Pathways sponsored trainings or events. For and in consideration of being permitted to participate in any or all of the Pathways Training Programs, presently and in the future, included related to travel, if any, Participant’s hereby fully releases and forever discharges and agrees to indemnifying, defend and hold harmless Pathways Core Training, Inc., including all instructors, facilitators, volunteers, sponsors, employees, advisors, directors, agents, officers, trustees, and affiliates of Pathways Core Training, Inc., from any and all liability (whether such liability arises in contract, tort, or otherwise) to Participant’s, Participant’s guardians, personal representatives, assigns, heirs, and next of kin, for any and all loss of damage on account of the injury to Participant’s property or a person, including the Participant’s death, arising directly or indirectly out of the any and all possible claims, known or unknown related to Participant’s attendance, participation, or both, any of the Pathways Training Programs, including any such damage, loss or injury that is caused by an act, or omission on the part of Pathways, inclusive of any negligent conduct, but excluding gross negligence or willful misconduct. It is Participant’s expressed intent that the above Release includes the Release by Participant and his or her guardians, personal representatives, heirs, next of kin, and assigns, of Pathways from the consequences as Pathways own negligence. Participant hereby acknowledges that he or she assumes any and all risks associated with attendance, participation, or both, in any Pathways Training Programs.

Additionally, Participant also acknowledges and agrees to the following: Participant understands that the Pathways Training Programs are not advice giving, therapy, psychotherapy, or any other form of counseling or treatment and Pathways is not responsible for identification, treatment or otherwise of any issues, known and unknown by Participant, relative to Participant’s that would require any such therapeutic or other type of intervention. If Participant needs any of those services, Participant agrees to seek such from a qualified provider. Participant agrees that if currently receiving therapy or medical treatment for a physical impairment, severe depression or mental illness, or if Participant has a condition requiring treatment by a physician or licensed mental health professional through the course of treatment, Participant agrees to seek the advice of his or her doctor or mental health professional prior to participating in any Pathways Training Programs. Participant is responsible for any and all decisions and actions taken as a result of or following his or her participation in any or all of the Pathways Training Programs, and is responsible for his or her own well-being. Pathways reserves the right to request Participant obtain an assessment by a mental health professional to attend any portion or all of the Pathways Training Programs. Participant acknowledges and agrees that Pathways may ask that Participant’s not complete any or all of the Pathways Training Programs if for any reason Pathways believes it is not in the best interest of the Participant or in the best interest of the other trainees for the Participant to continue.

Participant acknowledges it is important for Participant to verify he or she have sufficient insurance coverage while participating in the Pathways Training Programs and that he or she is responsible to secure such coverage if he or she does not already have it. Participant understands Pathways does not provide such coverage and that no insurance coverage may exist through Pathways to cover any injuries or damages which Participant’s may sustain as a result of his or her attendance, participation, or both, in the Pathways Training Programs. In addition, by execution of this Release, Participant grants Pathways permission and authority to use, in any form, now known or later developed, Participant’s oral or written comments, name, voice, image, or any other likeness, throughout the world, in any media form and type of publication and it irrevocably grants to Pathways any and all rights to said use without compensation. The terms of this Release are to be governed by the laws of Texas, excluding it’s choice of law provisions. Venue with respect to any dispute arising between Pathways and any other party, including Participant’s, that involve this Release, shall be exclusively in Dallas County and Tarrant County in Texas. Participant’s expressly consents to personal jurisdiction in said venue. Participant expressly agrees that this Release is intended to be as broad and inclusive as permitted by law. Each provision of this Release is severable and if one portion is invalid or illegal, such invalid or illegal portion shall not apply, but the remaining portions shall nevertheless remain in full force and effect. Participant understands the terms of this Release are contractual and not mere recitals, and that such terms are binding upon Participant, Participant’s guardians, heirs, personal representatives, and assigns. In executing this Release, Participant has not relied upon any statement or representation pertaining to this matter made by Pathways or any other person or entity, which is hereby released. Participant represents and warrants that he or she has carefully read this document and its contents and know its contents. And that Participant is 18 years of age or older and has full authority to execute this Release and that Participant has executed this Release voluntarily and as Participant’s own free act. Participant executes this Release fully intending to be bound by its terms.

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Physician's Name

First NameLast Name

Physician's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Are you currently under a physician's care?

Please expand:

Who should we call in case of emergency? Emergency Contact ( 1 )

First NameLast Name

Relationship:

Emergency Contact ( 1 ) Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact ( 2 )

First NameLast Name

Relationship:

Emergency Contact ( 2 ) Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

T-Shirt Size:

Any known allergies?

List all known allergies:

Are you currently taking medication?

List all current medications:

Are there any limits on your physical activities?

Please describe:

Should I require medical attention and or care while participating in the course / activity and I am unable to grant my consent to such medical attention and / or care, I hereby grant my consent for Pathways Core Training, Inc. to authorize any x-ray examination, an anesthetic, medical or surgical diagnoses, or treatment and hospital care or service, as may be deemed necessary by Pathways Core Training, Inc., provided such care or service is rendered to me under the supervision of a licensed physician or surgeon for the medical staff of a licensed hospital. I agree that I am responsible for any and all costs incurred for my medical care or treatments and I, together with my heirs, executors, administrators forever release Pathways over the course activity and the officers, directors, employees and authorized representatives of Pathways Core Training, Inc. Inc. from all claims, damages, actions, or causes of actions which may be incurred for my medical care and or treatments or which may occur due to any decisions which they make in respect to my medical care or treatment. I understand that this Trainee Medical History and Medical Release form is effective from the date signed until the conclusion of the entire course / activity and it is my responsibility to inform Pathways Core Training, Inc. of any changes to information disclosed herein. The undersigned certifies to Pathways Core Training, Inc. and the staff of the course activity that the information contained herein is, to the best of the undersigned’s knowledge, true, correct and accurate.

Date

Check-In Information

Participant Acknowledgement and Release Agreement

Pathways Core Training, Inc. Trainee Medical History / Medical Release Form