REGISTRATION FORM

"PARTNERING WITH POISE"

ALEXANDER TECHNIQUE (AT) BASED SELF-CARE COURSE
FOR CARE PARTNERS OF PEOPLE LIVING WITH
ALZHEIMER’S DISEASE OR RELATED DEMENTIAS

Times: Thursdays from 1:00pm-2:30pm

Dates: August 22 - October 24, 2019

Location: Mount Holly Historical Society, 131 South Main Street, Mount Holly NC 28120

Cost: Free for care partners

Registration is necessary. Please fill out the form below to secure your place.

This course if for care partners independent of their care receiver.

The program consists of a group class meeting for 90 minutes once a week for 10 weeks.
(NOTE: The first and last class are for two hours each.)

It is understood that some participants may not be able to attend every class.

If you would like to see video interviews with two care partner participants who have taken this course, you may go to: Betty - https://youtu.be/gvvikiDygFk Tom - https://youtu.be/awcN5b_eg3I

QUESTIONS? Karen Kleiner, Course Instructor Karen@anatomywise.com or 980-477-0508

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

Name

First Name

Last Name

Email Address

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I am caring for

My spouse or partner

My parent

My child

Another relative

My friend

Other

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" - Mount Holly NC