M2M Participation Waiver Form

  • Participation Waiver Form

  • Format: (000) 000-0000.
  • Are you 18 years or older?*
  • MEDICAL HISTORY: Do you have or had any of the following conditions?

  • ACCIDENT WAIVER AND RELEASE OF LIABILITY FORM

    Acknowledgment of Risks:

    I acknowledge that I am participating in Sports Medicine and Physical Therapy services provided by Made to Move, LLC (Made 2 Move) which may involve physical activity, exercises, and manual therapy techniques that have inherent risks involved with them. The risks from participating in these treatments include, but are not limited to, falls, sprains, strains, discomfort, redness of skin, soreness, bruising, or more serious injuries as well as any risks that may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained, or controlled by them, or because of their possible liability without fault. I voluntarily assume all of the risks associated with my participation with this event/service.

    Release of Liability:

    In consideration of being permitted to participate in Sports Medicine Physical and Physical Therapy services, I hereby waive, release, and discharge Made to Move, LLC (Made 2 Move), its staff, volunteers, and agents from any and all claims, demands, or causes of action for personal injury, property damage, or wrongful death that may arise from my participation, even if caused by the negligence of the released parties. I hold harmless and promise not to sue the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in this activity, whether caused by the negligence of release or otherwise. I acknowledge that Made to Move, LLC (Made 2 Move), and their directors, officers, clinicians, volunteers, representatives, and agents are NOT responsible for the errors, omissions, acts, or failures to act of any party or entity conducting a specific activity on their behalf.

    Medical Acknowledgement:

    I affirm that I have disclosed any medical conditions that may affect my participation in these services. I understand that it is my responsibility to consult with a medical professional regarding my fitness to participate. I certify that I am physically fit, have sufficiently prepared or trained for participation in this activity, and have not been advised to not participate by a qualified medical professional. I certify that there are no health-related reasons or problems which preclude my participation in this activity.

    Agreement to Follow instructions:

    I agree to follow all instructions provided by the Doctors of Physical Therapy and staff of Made to Move, LLC (Made 2 Move) during my participation. I understand that failure to do so may result in increased risk of injury.

    Consent for Treatment:

    I consent to receive Sports Medicine and Physical Therapy services as deemed necessary by the Doctors of Physical Therapy at Made to Move, LLC (Made 2 Move).

    I CERTIFY THAT I HAVE READ THIS DOCUMENT AND I FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND I SIGN IT OF MY OWN FREE WILL.

     

  •  

    PHOTO/VIDEO RELEASE 

    I hereby grant Made to Move, LLC (Made 2 Move) permission to use my likeness in a photograph, video, or other digital media (“photo”) in any and all of its publications, including web-based publications, without payment or other consideration.

    I understand and agree that all photos will become the property of Made to Move, LLC (Made 2 Move) and will not be returned.

    I hereby irrevocably authorize Made to Move, LLC (Made 2 Move) to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo.

    I hereby hold harmless, release, and forever discharge Made to Move, LLC (Made 2 Move) from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

  • Date*
     - -
  • Should be Empty: