This form must be completed by the medical model, not the course participant.
By completing this participation and liability waiver form, you ("you", "your", "medical model") fully comprehend and agree that you are solely responsible for establishing an agreement between yourself and the course participant ("Course Participant") who has contracted your medical model services for a continuing education course ("Event", "lab", "course") hosted by the Academy of Pelvic Health Physical Therapy ("APTA Pelvic Health", "Academy", "we", "us", "our"). You have agreed to provide medical model services to the Course Participant and agree to the following terms:
A. GENERAL
I. Participation. Each medical model is required to participate as the "Patient" during the Event and is required to complete and sign this form. You agree to provide medical model services to a Course Participant during all scheduled course lab activities that warrant a medical model. You understand that by participating as a medical model for the Event, you will be required to undergo several internal and external physical examination by various "therapists," which may include the Course Participant and other attendees of the course. You understand that as a medical model for the Course Participant, you must be present for all labs and skill checks during the Event. You understand that if you do not complete this form or you share any falsified information in this form, you will be removed from the Event.
II. Conduct. We are committed to providing a peaceful and harassment-free Event and we expect all models to behave appropriately and to treat everyone else at the Event with dignity and respect. You acknowledge that we reserve the right to remove you from the Event if we, in our sole discretion, consider your presence and / or behavior to create a disruption or to hinder the Event and / or the enjoyment and learning experience of other attendees or presenters. You understand that participants of all genders may be present in the room during the completion of lab activities where participants may be in a state of undress. Harassment or discriminatory language, behavior, or imagery is not allowed. Those who violate these standards may be removed from the Event.
III. Travel, Lodging, Meals. You understand that you are expected to attend the model-required parts of the course and are financially responsible for making your own travel, lodging, and meal plans accordingly in coordination with the course participant for which you are serving as a medical model. If you decide to cancel your model participation or if you have been removed from the Event, you understand that you are solely responsible for your own incurred expenses.
IV. Contracted Fees. If you charge a contracted rate for your medical model services, you understand that the Academy is not financially responsible for the contract and any associated fees you have agreed upon between you and the course participant that has contracted your medical model services.
V. Event Agenda. You acknowledge and agree that the Academy, in its sole discretion, reserves the right to change any and all aspects of the Event, including but not limited to, the Event name, themes, content, contact hours, program, speakers, performers, hosts, moderators, sponsors, venue, dates, and times. The Academy will make its best effort to communicate critical changes to the agenda should changes arise.
VI. CEU Credit. As a medical model, you are not eligible to receive continuing education credit (CEU) for participating in the lab activities of the course.
VII. Auditing. You understand that you will be required to leave the classroom during non-lab activity times. You understand that if you wish to attend the full course as an auditor, there is a registration fee for auditing the course. You understand that it is your responsibility to contact the Academy at https://www.aptapelvichealth.org/contact-us if you are interested in auditing the course. You understand that auditing the course does not grant you continuing education units (CEU).
VIII. Course Cancellation: The Academy reserves the right to cancel the Event for any reason. In the event the Academy cancels an Event, you understand that it is the responsibility of the course participant to which you are providing medical model services to notify you of the cancellation. The Academy is not responsible for providing reimbursement or a refund for any travel, lodging, or other expenses you have incurred in preparation for this Event. You are financially responsible for making and canceling your own travel arrangements.
B. LAB PARTICIPATION
I. Menstrual Cycle. For Events that require internal lab examinations, you understand that you will still be expected to fully participate in the Event Lab activities while you are on your menstrual cycle. You understand that you will be provided a menstrual cup to hold back menstrual flow in order to allow participation in internal lab examinations.
II. Breastfeeding. If you are a lactating mother and you need to pump during the Event, you understand that you will plan to do so during Event break times and lunch hours. You understand that is is your responsibility to contact the Academy in advance to coordinate providing a space at the course site for you to pump.
III. Tests, Measures, Interventions: You understand that these tests, measurements, and/or interventions performed during the Event lab activities are being performed for the sole purpose of demonstration and practice by participants and are not intended to be diagnostic or therapeutic. You understand the external and internal examinations that may be performed on you during the Event pose no greater risk than a standard gynecologic or colorectal examination. If you have a health condition or health-related concern regarding your participation, you understand that it is your responsibility to disclose those conditions and concerns to the Academy. By participating in this Event as a medical model, you understand and assume all risks and responsibilities for your health and medical needs.
IV. Medical Condition Disclosures. You understand that it is your responsibility to inform the Academy about any relevant physical, emotional, or medical conditions, as well as any limitations or sensitivities that may affect your participation. You agree to carefully read and review the Medical Model Guidelines. By completing this form, you agree to the guidelines.
a. Pregnancy. If you are pregnant, you understand that you cannot participate as a “patient” in labs for CAPP-Pelvic Events and the other select Events that require participation in intravaginal examinations unless your physician provides written permission for your full participation after reading the Event course description and lab outlines. If you do not have written physician permission, then you must provide a live female patient model to stand in for you. Due to the repetition and extensive nature of these labs, the Academy recommends that pregnant participants provide a model to standing their place. By registering for this Event, you assure the Academy that you have honestly and thoroughly addressed all health-related questions, revealing all relevant information crucial to your involvement in the Event and have successfully uploaded all the required physician permission notes through the designated Medical Disclosures Form at least seven (7) days prior to the Event.
b. Other Conditions. If you have undergone surgical procedures or experienced recent injuries, you must ensure that you have consulted with your physician(s) regarding the lab participation expectations and requirements for this course and obtained all the necessary permission slips from them to participate in the Academy's Event. By registering for this Event, you assure the Academy that you have honestly and thoroughly addressed all health-related questions, revealing all relevant information crucial to your involvement in the Event and have successfully uploaded all the required physician permission notes through the designated Medical Disclosures Form at least seven (7) days prior to the Event.
C. MEDIA RELEASE
The Academy reserves the right to use photographs and recordings of any Event participant for its promotional and educational materials. You understand that the Academy will make its best effort not to film, record, or photograph you in a state of undress. In the event, a photo or video is taken of you in any state of undress by an Academy agent, staff member, host venue, or contractor for Academy's marketing and educational purposes, the Academy will make its best effort to blur your face and name tag. By participating in the Event, you hereby give and grant to Academy the irrevocable right, permission, and license to take photos and/or audio/video record you at this event and publish, reproduce, and otherwise use the photos and audio/video recording in all forms and media for educational, trade, web, advertising, and all other lawful purposes without compensation. You realize and discharge the Academy from all forms of claims and liability related to your photo and audio/video recording. You agree that the photos and audio/video recording shall be the sole property of the Academy and you grant, assign and transfer to the Academy all necessary rights to that effect. By granting permission for photography and audio/video recording, you release the Academy from all forms of claims and liability related to the use of your photos and audio/video recordings.
Photographs, short audio, and video clips taken and recorded by you may be used for social media, blogging, and press coverage of the Event. All subjects in photographs and video clips taken by you must be fully clothed and professionally represented. Without express, written permission from the Academy, audio and video clips published must be non-contiguous clips of ten seconds or less and photographs must not contain Event materials such as the inside of course manuals, handouts, charts, images, diagrams, and other educational content protected under copyright. Subject to the foregoing limitation, all audio and video recording of Event sessions is strictly prohibited.
D. DATA AND PRIVACY POLICY
The Academy is committed to protecting the privacy of its event attendees, clients, and customers. Your information is kept private and is used for the purposes of communicating with you about the Event and other related topics. You understand and agree that the Academy reserves the right to share your contact information, including your full name, e-mail address, phone number, and/or mailing address with relevant parties such as Academy employees, faculty contractors, course participant, host venue staff, and other entities involved in the Event.
E. LIABILITY WAIVER AND RELEASE
You have read and understand the terms and conditions outlined in this agreement. On behalf of yourself, your family, heirs, and personal representatives, you hereby forever release and hold harmless the Academy and its officers, directors, members, employees, contractors, consultants, and agents, as well as the facility and staff where the course is being held, from and against any and all liability for, and waive all claims against such persons with respect to, any harm, personal injury, or damage, including serious illness or even death, arising out of your participation in the Event, even if caused by the negligence of any of the above persons (provided that no person who engaged in gross negligence or intentional wrongdoing is protected by this section). You affirm that you understand and agree that it is your responsibility to only apply interventions within your scope of practice (PT) and scope of work (PTA) as determined by the state practice act governing the location where you are providing healthcare services.
F. SEVERABILITY
ANY PART OF THIS AGREEMENT FOUND BY A COURT TO BE VOID OR UNENFORCEABLE SHALL BE INEFFECTIVE TO THE EXTENT OF SUCH PROHIBITION OR UNENFORCEABILITY WITHOUT INVALIDATING THE REMAINING PROVISIONS HEREOF.