As evidenced by my signature below, I agree to participate, and understand that it is my choice to participate, in the Cancer Support Community support group(s) and other programs.

I acknowledge that, with group therapy and other CSC classes, there is risk of disclosure of personal and confidential information by participants in the group to individuals outside of the group. I agree that I will not disclose personal information learned by me during the course of any group session and will protect each participant's right to confidentiality.

I agree to hold the group facilitator and/or the Cancer Support Community at Prisma Health Cancer Institute, Cancer Support Community at Cancer Survivors Park, Cancer Survivors Park Alliance (CSPA), Prisma Health System, The Center for Integrative Oncology and Survivorship (CIOS) and all officers, agents, employees, representatives, executers harmless from any claims or liability resulting from my disclosure of confidential information to a third party outside of a group session. I further agree not to hold her/him/they responsible and release him/her/they from the same, for/from any claims of liability that I could assert as a result of disclosure of my confidential information by co-participants in the group(s).

I understand that with any movement class, as is the case with any physical activity, that the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated.

I understand that it is encouraged to seek physician approval before beginning any movement/exercise practice.  I acknowledge that I have either been given my physician’s permission to participate, or that I have decided to participate in the activity(ies) without the approval of my physician. 

I understand that I am responsible for monitoring my own condition throughout the class(es) and should any unusual symptoms occur, I will cease my participation and inform the instructor/facilitator of my symptoms.  I understand that for safety reasons as well as cohesion within the group it is encouraged that if in a virtual class I keep my camera, if I have one, on.

I affirm that I alone am responsible to decide to participate in the Cancer Support Community (CSC) programs.  In consideration of being allowed to participate in the CSC programs, I hereby waive, release and forever discharge Prisma Health System, The Cancer Institute, Prisma Partners in Health, Cancer Support Community at Prisma Health Cancer Institute, Cancer Support Community at Cancer Survivors Park, Cancer Survivors Park Alliance (CSPA), The Cancer Support Community, The Center for Integrative Oncology and Survivorship (CIOS) and all officers, agents, employees, representatives, executors and all others from any and all responsibilities or liability for any and all injuries or damage arising out of or related to this activity and program.  I take this action for myself, my executors, administrators, personal representatives, heirs, next of kin, successors and assigns.

In signing this consent form I affirm that I have read, accept and understand it in its entirety and have freely done so on the date indicated.