WORKSHOP REGISTRATION PAGE

SIBLEY HOSPITAL - FREE WORKSHOP

MANAGE SYMPTOMS OF PARKINSON'S & CARE PARTNER CHALLENGES
USING ALEXANDER TECHNIQUE (AT) PRINCIPLES

An introduction to basic Alexander technique (AT) principles that can
improve general functioning, increase confidence, and improve overall quality of life.
These principles can be applied during normal daily activities as well as during any exercise program.

For People Living with Parkinson's (PwP) and their Care Partners

Date: Wednesday, September 5, 2018

Location:

Sibley Medical Building - Building A
5215 Loughboro Road, N.W.
Washington, D.C. 20016

Room: Conference Room 1

Time: 2:00pm-4:00pm

Cost: Free

Registration is necessary as space is limited.

If you are coming with another person, please register separately so we know how many people are coming. Both care partners and people living with a Parkinson's diagnosis should register separately.

CONTACT IF NEEDED: Monika Gross, 828-254-3102

Please fill out and Submit the Registration Form & Waiver. Thank you, and we look forward to seeing you on Wednesday, September 5 from 2:00pm-4:00pm!

Name

First Name

Last Name

Email Address

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What brings you to our workshop?

Please check one

I am a person living with Parkinson's

I am a care partner of a person living with Parkinson's

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.

Washington DC (Sibley Hospital) - Alexander technique for Parkinson's Public Workshop