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Today's Date(Required) Month Day Year Name(Required) First Last Phone(Required)Email(Required) How did you hear about this event?(Required) Why do you want to be at AMPT Summit with us?(Required) Have you attended an AMPT workshop in the past?(Required)YesNoIf yes, which AMPT workshop did you attend? If no, are you willing and able to participate in online training prior to attending the AMPT Summit? How will you use AMPT in practice? Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Date of Birth(Required) Month Day Year I understand that I am participating as a live model for the purpose of demonstrating chiropractic techniques during an Advanced Muscle Palpation event sponsored by ChiroWay Chiropractic, LLC. Technique/Procedures that may be Demonstrated without compensation for the model: Cervical, Thoracic and Lumbosacral Chiropractic Adjustments. Advanced Muscle Palpation Instructors are highly qualified to teach and demonstrate procedures, however, as with any presentation, there is a chance of injury. Note any physical limitations or identified risks within this document. Should an injury occur, I understand my responsibility to contact ChiroWay Chiropractic, LLC so that appropriate action can be taken.Physical Limitations (if any) of Model: Identified Risks (if any) of Model: Cervical Consent for Cervical Chiropractic AdjustmentsThoracic Consent for Thoracic Chiropractic AdjustmentsLumbosacral Consent for Lumbosacral Chiropractic AdjustmentsAdvanced Muscle Palpation Technique (AMPT) Terms and Conditions(Required) I agree to AMPT Terms and Conditions.By attending this AMPT Workshop/Seminar; you acknowledge and agree to the following terms and conditions: Content and Copyright: Ownership of Content: All materials, teachings, images, and content presented during this seminar are the intellectual property of Advanced Muscle Palpation Technique (AMPT). This includes but is not limited to verbal instructions, written materials, diagrams, and other educational content. No Reproduction or Distribution: The information provided in this seminar is for personal educational purposes only. Any reproduction, recording, copying, distribution, or sharing of this material, in any form or by any means, including but not limited to photography, videography, audio recordings, or written notes for public dissemination, is strictly prohibited without the express written consent of AMPT. No Recording Devices: To protect the integrity and research of the material, attendees are prohibited from using any video, audio, or photographic devices during the seminar without prior approval. Any unauthorized recording may result in removal from the seminar without a refund. Enforcement of Copyright: AMPT reserves all rights to enforce its copyright and intellectual property rights. Unauthorized use, sharing, or reproduction of seminar materials will result in appropriate legal action. Release of Image, Likeness, and Testimonial Consent: I, the undersigned, hereby grant Advanced Muscle Palpation Technique (AMPT) and ChiroWay Chiropractic, LLC the irrevocable right and permission to use photographs, video recordings, audio recordings, and testimonials of me taken or recorded during the workshop or event for marketing, educational, and promotional purposes, including but not limited to use in print, digital, and online media. By signing this release, I acknowledge and agree to the following: Use of Image and Likeness: I authorize AMPT and ChiroWay Chiropractic, LLC to capture and use my image, likeness, and voice in photographs, videos, or audio recordings. I consent to the use of these materials in any manner that AMPT and ChiroWay Chiropractic, LLC deems appropriate, including but not limited to social media, websites, promotional materials, advertisements, and educational content. Use of Testimonials: I grant AMPT and ChiroWay Chiropractic, LLC permission to use any written or verbal testimonials I provide during or after the workshop. These testimonials may be edited for length or clarity and used in promotional or educational materials. No Compensation: I understand that I will not receive any monetary compensation for the use of my image, likeness, or testimonials. I agree that these materials are the property of AMPT and ChiroWay Chiropractic, LLC, and that I have no claim to any compensation, royalties, or other financial benefits. Waiver of Rights: I waive any right to inspect or approve the final products that incorporate my image, likeness, voice, or testimonials, as well as any written copy or edited versions that may accompany these materials. I release AMPT and ChiroWay Chiropractic, LLC from any liability related to the publication or use of my image, likeness, or testimonials, including any claims for defamation, invasion of privacy, or rights of publicity. Duration: This release is irrevocable, perpetual, and worldwide. It applies to all media formats and can be used in multiple instances across different platforms and timeframes. Informed Consent: I understand that I am willing to participate as a live model to demonstrate the Chiropractic Technique (Chiropractic Analysis/Vertebral Adjustment) taught during an AMPT Workshop/Seminar. If a model receives a chiropractic adjustment during the workshop, they will not be charged for the service. AMPT Instructors are Chiropractors licensed in their state of residence/practice and highly qualified to teach and demonstrate procedures. Informed Consent: I acknowledge that I am willing to participate as a live model to demonstrate AMPT by an AMPT Instructor/Chiropractor. The findings of this analysis have been explained to me, and based on this, I voluntarily consent to receive a vertebral adjustment as part of the demonstration. Vertebral adjustment(s) during this workshop/seminar are intended to reduce vertebral subluxation and improve overall quality of life. However, I am aware that, like all health care procedures, there are inherent risks. Although serious complications from vertebral adjustments are extremely rare, the following potential risks have been disclosed to me: temporary soreness or increased symptoms (it is common to experience temporary discomfort following a vertebral adjustment), dizziness, nausea, or flushing (while rare, these symptoms may occur during or after care and should be reported to the AMPT Instructor/Chiropractor), fractures: individuals with conditions that weaken bones, such as osteoporosis, may be at risk of fractures (I understand it is important to inform the chiropractor of any bone-weakening conditions), disc herniation or prolapse (pre-existing disc conditions may worsen, and it is crucial to notify the chiropractor if symptoms change), stroke (although current research does not support an excess risk of stroke from chiropractic care, I understand the potential association between stroke and visits to healthcare providers, particularly for those with neck pain and headaches), bruising (soft tissue bruising or soreness may occur following a vertebral adjustment). Should an injury occur, I understand my responsibility to contact ChiroWay Chiropractic, LLC so that appropriate action can be taken. I confirm that I have read and fully understand this informed consent form. I have had the opportunity to discuss any concerns or questions with the AMPT Instructor/Chiropractor prior to signing, and these questions have been answered to my satisfaction. My participation is entirely voluntary, and I freely consent to receive demonstrational chiropractic adjustments. Assumption of Responsibility: By participating in this workshop hosted by AMPT and ChiroWay Chiropractic, LLC, I understand that additional activities may take place before, during, or after the scheduled event. These activities may include, but are not limited to, social gatherings, exercise, recreational activities, or other events that are not directly related to the chiropractic workshop or its official agenda. I acknowledge that my participation in any such activities is entirely voluntary and is done at my own discretion. I understand that AMPT and ChiroWay Chiropractic, LLC are not responsible for, nor do they assume any liability for, any injuries, accidents, or damages that may occur as a result of my participation in these activities. I hereby agree to assume full responsibility for any risk of injury, illness, damage, or loss, including but not limited to personal injury or property damage, that may occur as a result of my voluntary participation in these non-workshop-related activities. I release and discharge AMPT and ChiroWay Chiropractic, LLC, their employees, agents, instructors, and representatives from any and all liability, claims, demands, actions, or causes of action related to my participation in such activities. Furthermore, I confirm that I am in a state of condition capable of participating in any additional activities I choose to engage in. I agree to hold AMPT and ChiroWay Chiropractic, LLC harmless from any injury, illness, or harm that may arise from my participation in any extracurricular activities associated with the event. Release of Liability: I, the undersigned, voluntarily choose to participate in the Advanced Muscle Palpation Technique (AMPT) Workshop hosted by ChiroWay Chiropractic, LLC. I understand that the activities involved in this workshop, including but not limited to chiropractic adjustments, demonstrations, physical activities, and hands-on techniques, may involve certain risks, including potential injury or discomfort. In consideration of being allowed to participate in this workshop, I hereby acknowledge and agree to the following: Assumption of Risk: I acknowledge that I am voluntarily participating in the workshop and assume all risks, both known and unknown, associated with my participation. This includes, but is not limited to, risks of injury, soreness, discomfort, and any potential exacerbation of pre-existing conditions. Medical Condition: I affirm that I am in good health and capable of participating in the workshop activities. I understand that it is my responsibility to inform the workshop instructors of any known medical conditions, health concerns, or limitations that may affect my ability to safely participate. If I experience any pain or discomfort during the workshop, I will immediately notify the instructor and discontinue participation. Release of Liability: I hereby release and discharge Advanced Muscle Palpation Technique (AMPT), ChiroWay Chiropractic, LLC, their officers, employees, agents, and representatives from any and all liability, claims, demands, actions, or causes of action related to any injury, damage, or loss arising out of or in connection with my participation in the workshop. This includes, but is not limited to, claims for negligence or any other cause. Indemnification: I agree to indemnify and hold harmless AMPT, ChiroWay Chiropractic, LLC, and their representatives from any claims, damages, costs, or liabilities arising from my actions or participation in the workshop, including any third-party claims related to my conduct during the event. Voluntary Participation: I confirm that my participation in the workshop is voluntary, and I fully understand the nature of the activities involved. I have had the opportunity to ask questions regarding the risks associated with the workshop and am satisfied with the information provided. No Guarantees: I understand that chiropractic adjustments and techniques provided during the workshop are for educational and demonstrational purposes, and no guarantees or assurances have been made as to the outcome or benefits of my participation. Release: By signing this terms and conditions, I acknowledge that I have read and understood its contents and agree to be bound by its terms. I understand that this is a legally binding document and that by signing it, I am waiving certain legal rights.Electronic Signature(Required) Full Name Date(Required) MM slash DD slash YYYY Note: Any advice or chiropractic procedures that are demonstrated or performed in this event are not intended to diagnose, mitigate or prescribe the use of any technique as a form of treatment for any physical conditions, symptoms or diseases. Directly consult with a qualified health care professional for any chiropractic or medical advice. In addition to the benefits of chiropractic care, one should also be aware of the existence of some risks. Risks associated with some chiropractic care may include soreness, musculoskeletal sprain/strain, and fracture. In addition, there have been reported cases of stroke associated with chiropractic care. Research and scientific evidence does not establish a cause and effect relationship between chiropractic care and the occurrence of stroke; rather studies indicate that people may be consulting chiropractors when they are in the early states of a stroke. In essence, there is a stroke already in process. However, you are being informed of this reported risk.
