REGISTRATION FORM

"PARTNERING WITH POISE"

ALEXANDER TECHNIQUE (AT) BASED COURSE

FOR CARE PARTNERS OF PEOPLE LIVING WITH PARKINSON'S DISEASE

@ CENTER FOR FAMILY WELL-BEING

Dates: Tuesdays starting October 2, 2018

Location:

Center for Family Well-being
5039 Connecticut Avenue NW #7
Washington DC 20008

Time: 10:30am-12:00pm

Cost: Free

Registration is necessary.

The program consists of a group class meeting for 90 minutes once a week for 10 weeks. It is understood that some participants may not be able to attend every class.

This course is part of an ongoing research study through the University of Idaho. You will be sent an Informed Consent Form to review that explains everything about the study. Then if you decide to participate you will be scheduled at your convenience for a pre-course assessment session.

If you would like to hear from others who have taken this course, video interviews from other care partners who have participated in this course may be viewed at: https://www.vimeo.com/thepoiseproject

QUESTIONS? Monika Gross, 828-254-3102

Please fill out and Submit the Registration Form & Waiver. Someone will contact you then to confirm your participation and with information about the research study.

Name

First Name

Last Name

Email Address

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Would you like to receive our newsletter?

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 images or videos taken of me during any of The Poise Project's one-to-one instruction, group classes, workshops, programs or events may be used by The Poise Project for archival documentation 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 WRITE YOUR NAME BELOW TO INDICATE YOUR SIGNATURE AGREEMENT TO THIS RELEASE AND WAIVER.

"Partnering with Poise" at Center for Family Well-being