Burlington Respite Classes

BURLINGTON RESPITE CLASS

(FOR CARE RECEIVERS OF BURLINGTON CARE PARTNERS' CLASS PARTICIPANTS)

Care Partner Class Participant - Please fill out this form in order for your care receiver (PlwPD) to be able to participate in any of the respite classes. Thank you!

Name of Care Partner Class Participant

First Name

Last Name

Name of Person Living with Parkinson's

First Name

Last Name

Email Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

Does the PlwPD need to have someone with them at all times, or can the teacher let them leave independently?

Does the PlwPD have any mobility issues? Please elaborate.

Does the PlwPD have any balance issues? Have they had any falls? Please elaborate.

Anything else the instructor should know about the PlwPD?

RELEASE AND WAIVER I do hereby release, waive and discharge The Poise Project ("The Poise Project") and their affiliates, trustees, directors, officers, employees, volunteers, assistants and agents (“Releasees”) from any and all liability for injury, loss, damage, obligation, expense or penalty, including attorneys’ fees, that I may cause or sustain in connection with my participation in The Poise Project's one-to-one instruction, group classes, workshops, programs or events whether caused by the negligence or carelessness of Releasees or otherwise. I understand that Releasees do not have medical personnel available at their one-to-one instruction, group classes, workshops, programs or events, and I agree that Releasees assume no responsibility for any injury or damage that might arise out of or in connection with my participation with any of The Poise Project's activities. By signing below, I knowingly and voluntarily assume all such risks, and assume sole responsibility for any accident or injury to myself and other persons or property arising out of or in connection with participation in The Poise Project's one-to-one instruction, group classes, workshops, programs or events. In addition, I have adequate coverage under a health and accident insurance policy applicable to the activities in which I may engage. I further agree that any photos or videotape images taken of me during any of The Poise one-to-one instruction, group classes, workshops, programs or events may be used by The Poise Project for archival documentation, or for scientific or educational or publicity purposes. By agreeing to this Release and Waiver by indicating such in the check box below, I represent that I have read its contents, that I understand it and that I agree to it voluntarily as my own free act and deed. I further state that I am at least eighteen (18) years of age, am fully competent to sign this document and that I execute this Release in consideration of my participation in The Poise Project's activities and programs, fully intending to be bound by same. By submitting this form, I indicate my agreement to this Release and Waiver.

* PLEASE HAVE THE CARE RECEIVER ENTER THEIR NAME BELOW TO INDICATE THEY UNDERSTAND AND AGREE TO THIS WAIVER WITH THEIR NAME TYPED BELOW INDICATING THEIR AGREEMENT TO THIS RELEASE AND WAIVER.