Acknowledgement of Risk and Waiver of Responsibility
I hereby give permission for myself or my child/children to participate in classes/events conducted by Power Up Physical Therapy & Fitness, LLC (Annette Thomas, MSPT), Seacoast Play Works Therapy, PLLC (Kristen M. Goodrich, OTR/L), More Than Words Counseling Services (Susie Curtis, LCMHC), Motivations by K (Kayla Ouellette), Sharon Bridson, and Emily Booth, MS, CCC-SLP. I understand that it is my responsibility to carry my own accident and medical insurance. In the event of an injury or accident, I authorize customary medical treatment if it becomes necessary, and transportation and emergency medical services if warranted. The enrolled child/children is/are capable of participating in fine and gross motor classes and have had a physical in the last (12) twelve months. If I am pregnant, I acknowledge that an OBGYN or midwife has approved me for participation in this class or activity. Any activity involving motion, jumping, rolling, running, etc. involves the possibility of serious, permanent or fatal injury. I understand the risks of participating in fine/gross motor activities. Therefore, in consideration for allowing myself or my child/children to use the equipment and facility, I hereby forever release Power Up Physical Therapy & Fitness, LLC (Annette Thomas, MSPT), Seacoast Play Works Therapy, PLLC (Kristen M. Goodrich, OTR/L), More Than Words Counseling Services (Susie Curtis, LCMHC), Motivations by K (Kayla Ouellette), Stillwater Counseling (Beth Brown, LICSW, RPYT) and Emily Booth, MS, CCC-SLP from all liability for any and all damages and injuries suffered by myself or my child/children while under the instruction, supervision or control of the above listed entities. This acknowledgement of risk and waiver of liability, having been read thoroughly and understood completely is signed voluntarily as to its content and intent.
Email address *
Which activity will you be attending? *
If you are coming to Open Gym or Camp, please list number of children and ages, along with any special needs we can help accommodate
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Photo Consent: I understand that the therapists and contractors at Therapy Square occasionally take photos of participants for advertising, promotional, media or social media purposes. These photos are never used in conjunction with names or personal identifiers. I agree that my photo or my child’s photo can be used by the staff at Therapy Square in this capacity. *
By signing this Electronic Signature Acknowledgment Form, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. I agree to the above Acknowledgement of Risk and Waiver or Liability. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding. (Type NAME AND DATE to electronically sign) *
Full Name and Date in mm/dd/yyyy Format
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