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5Peaks Participant Form
Please fill out the online form and submit to finalize your registration.
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Name *
Email *
Phone Number *
What is the Class or Event you are registering for? *
Have you participated in a 5Peaks Class or Event in the past? *
If yes, which Class or Event was that? *
If a meal is included with your Event, do you have any dietary restrictions?  If yes, please describe.
What is your motivation for taking the Class or Event?  What do you hope to get out of the experience? *
How did you hear about Jennifer Van Rossum/5Peaks?
DISCLAIMER AND WAIVER OF LIABILITY:  By signing my name below, I expressly acknowledge and agree to all of the following. 1) This program specifically does not offer any therapeutic services and is solely for educational purposes. 2) While the program may be conducted by a Licensed Professional Counselor, the program is NOT providing any clinical services and does not constitute therapy. 3) No client/patient relationship is created by my attendance in this program. 4) This program is not intended to treat any of the programs' participants. 5) I hereby hold harmless and release, waive, discharge and covenant not sue Jennifer Van Rossum/5Peaks, LLC from any and all claims associated with my participation in the program.  I further expressly agree that the foregoing waiver is intended to be as broad and inclusive as is permitted by the law of the State of Wisconsin. 6) I agree to indemnify and hold Jennifer Van Rossum/5Peaks, LLC harmless from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorneys' fees brought as a result of my involvement in the program. 7) If any portion of the Disclaimer and Waiver of Liability is held invalid, the remaining portions shall, notwithstanding, continue in full legal force and effect. *
I understand that Jennifer Van Rossum, MA, LPC is a mandated reporter and is ethically and legally responsible to report suspected abuse and neglect. *
Electronic Signature of full name *
Today's date *
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