Uniquely-Wired Child Seminar 2020
3/7/2020, 8:30-1:00. Workshops start at 9:00am.
First Name: *
Last Name: *
Email: *
Will only be used to notify you of changes to the seminar schedule.
Phone Number: *
Will only be used if we need to notify you of changes to the schedule last-minute.
Attending (check all that apply): *
I heard about this seminar from (check all that apply): *
Release of Liability: *
This is a legally binding Consent Form and Release of Liability made voluntarily by me, the undersigned Releaser, on my own behalf, and on the behalf of my heirs, executors, administrators, legal representatives and assigns to SENSE ABLE BRAIN. By the execution of this waiver of liability form, I acknowledge that the child listed above is/are capable of participating in the activities. I also assume all risks of the student participating in the activities, whether such risks are known or unknown to me at this time. I release and hold harmless this organization, leaders, employees, contractors, volunteers, and any agents from any claim the student or I may have due to the result of any injury or illness incurred during participation in the Sense Able Brain activities. I accept and assume full responsibility for any and all injuries, damages, and losses that may occur to the student from any participation in the activities. In an emergency, I acknowledge that I am solely responsible for all medical and other costs arising out of bodily injury or any loss sustained through participation in this activity. I authorize program/office/facility staff to secure any licensed hospital, physician, and/or medical personnel for any treatment deemed necessary for the participant's immediate care. By signing my name below I certify that I am authorized to make decisions for the above named child and that I agree to this liability release as written.
Photo/Video Release: *
I hereby grant Sense Able Brain Therapy & Learning the irrevocable right and permission to use photographs and/or video recordings of myself and/or my family members, including but not limited to my child(ren) on their website and other websites and in publications, promotional flyers, educational materials, derivative works, or for any other similar purpose without compensation to me. I understand and agree that such photographs and/or video recordings of myself and/or my family members, including but not limited to my child(ren) may be placed on the Internet. I waive the right to approve the final product. I agree that all such portraits, pictures, photographs, video and audio recordings, and any reproductions thereof, and all plates, negatives, recording tape and digital files are and shall remain the property of Sense Able Brain. I hereby release, acquit and forever discharge Sense Able Brain, its current and former trustees, agents, officers and employees of the above-named entities from any and all claims, demands, rights, promises, damages and liabilities arising out of or in connection with the use or distribution of said photographs and/or video recordings, including but not limited to any claims for invasion of privacy, appropriation of likeness or defamation.
Signature: *
By typing your name in this box, you certify that you are the above named individual, and that you agree to the liability releases as written.
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