Group Participation Form

I, _____________________________, (client/guardian name) amaware of the risks of participating in the program/activities, andassume all risks, foreseeable and unforeseeable, in any wayconnected with my participation herein. I am aware that Keys ToCommunicate LLC is not responsible for any lost, stolen, or damagedvaluables or property. I agree not to institute any claims or legal actionagainst Keys To Communicate LLC for any claim released by thisAgreement. I agree to protect, defend, and indemnify Keys ToCommunicate LLC, and any of its employees or owners in regards toany claim or expenses (including attorneys’ fees, claims by a thirdparty or otherwise, that might be made on my behalf) in any wayconnected with a claim related to my participation in theprogram/activities. I have read and fully understand, agree to, andvoluntarily accept all provisions of this Release of Liability and Waiver,Assumption of Risk, and Indemnification. This release will begoverned by and construed in accordance with the laws of the State ofNew Jersey and venue for all challenges of this waiver shall berestricted to the federal or state courts located within MiddlesexCounty. I am signing this Agreement freely, voluntarily, andcompetently and I am at least eighteen (18) years of age or theguardian of the client referenced within this agreement.

Keys To Communicate, utilizes IVY PAY, which is a paymentsystem designed specifically for therapists and their clients.Ivy Pay works with your debit card, credit card, HSA or FSAaccount. It is HIPAA secure and it keeps our therapeuticrelationship confidential. It is easy to use and provides acompletely touchless payment process. Ivy Pay is aHIPPAA-compliant app that uses encryption, two-factorauthentication, and adheres to payment card industry datasecurity standards.Ivy Pay creates a mobile invoice for easily processing creditscards and tracking payment by cash or check. Ivy Pay is veryeasy to navigate and requires a mobile number (no landlines)for every client listed and mobile numbers cannot beduplicated.If you are in agreement to this form of payment, I will sendyou an invitation text to set up your account. This will need tobe completed before your upcoming appointment time.

By signing this document, I authorize the use of my electronic signature for all necessary billing and payment processes completed through DDD Public Partnerships. I acknowledge that billing will be processed electronically, and I grant permission for the participant's electronic signature to be applied to billing records on the date the billing is completed.