Rooted & Resilient
Black Maternal Health Wellness Fair
Attendee Information
Please fill name and contact information of attendees.
Your Name
*
Mr.
Mrs.
Miss.
Prefix
First Name
Last Name
Email Address
*
example@example.com
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Will you have a guest with you?
*
Yes
No
Dietary Restrictions
*
Please Select
None / No Restrictions
Vegetarian
Vegan
Gluten-Free
Dairy-Free / Lactose Intolerant
Nut Allergy
Guest Name
Mr.
Mrs.
Miss.
Prefix
First Name
Last Name
Email Address
example@example.com
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Dietary Restrictions
*
Please Select
None / No Restrictions
Vegetarian
Vegan
Gluten-Free
Dairy-Free / Lactose Intolerant
Nut Allergy
Would you like to be updated about the upcoming events?
Yes
No
Liability Waiver
By signing below, I acknowledge that I am voluntarily participating in the event hosted by Pregnant with Possibilities Resource Center. I understand that this event may include activities such as wellness exercises, educational discussions, guided breathing practices, and other interactive programming. I acknowledge that participation in these activities carries some inherent risks. I agree to assume full responsibility for any risks, injuries, or damages that may occur as a result of my participation in this event .I hereby release, waive, and discharge Pregnant with Possibilities Resource Center, its staff, volunteers, partners, sponsors, and the Maple Heights Senior Center from any and all liability, claims, demands, or causes of action arising from my participation in this event. I understand that this event provides educational and wellness information only and is not intended to replace medical advice, diagnosis, or treatment from a licensed healthcare provider.
Photo Release
I grant Pregnant with Possibilities Resource Center permission to photograph, video record, or capture my likeness during this event. I understand that these photos or recordings may be used for purposes including but not limited to:• Organizational marketing• Social media and website promotion• Newsletters and publications• Grant reporting and community outreach. I grant permission for my image, likeness, and voice to be used without compensation and understand that these materials may be used in perpetuity by Pregnant with Possibilities Resource Center. If I do not wish to be photographed or recorded, I will notify event staff upon arrival.
By signing below, I confirm that: I have read and understand this waiver and release of liability. I voluntarily agree to participate in the event. I grant permission for photo and media use as described above.
Signature
*
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