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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 AdjustmentsGENERAL LIABILITY WAIVER(Required) I agree to the general liability waiver.1. Acknowledgment of Risks I, the undersigned participant, acknowledge that I am voluntarily attending an Advanced Muscle Palpation Technique Workshop, which is a business professional event that may include, but is not limited to, the consumption of alcoholic beverages and swimming. I understand that participation in these activities involves certain inherent risks, including but not limited to the risk of injury, illness, or death. I further acknowledge that my participation is entirely voluntary, and I am not required to stay overnight at the event location. 2. Assumption of Responsibility I fully understand and agree that I am responsible for my own actions and behavior during the Event. I acknowledge that it is my responsibility to know my own limits, particularly with regard to the consumption of alcohol and participation in swimming or any other activities, and to act responsibly at all times. 3. Release of Liability In consideration of being permitted to participate in the Event, I hereby release, waive, discharge, and covenant not to sue [Event Organizer's Name], its officers, employees, agents, and affiliates (collectively referred to as the “Released Parties”) from any and all liability, claims, demands, actions, or causes of action whatsoever arising out of or related to any loss, damage, injury, or harm, including death, that may be sustained by me or any property belonging to me, whether caused by the negligence of the Released Parties or otherwise, while participating in the Event or any activities associated with the Event. 4. Indemnification I agree to indemnify and hold harmless the Released Parties from any loss, liability, damage, or costs, including court costs and attorneys’ fees, that may incur due to my participation in the Event, whether caused by the negligence of the Released Parties or otherwise. 5. Alcohol and Swimming Acknowledgment I acknowledge that the consumption of alcohol and participation in swimming are entirely voluntary. I understand that consuming alcohol may impair my judgment, coordination, and ability to swim safely. I agree not to hold the Released Parties responsible for any incidents, injuries, or damages that may result from my consumption of alcohol or participation in swimming activities. 6. Medical Treatment Authorization In the event of an emergency, I authorize the Released Parties to obtain medical treatment for me, if necessary, and I agree to bear the cost of any such treatment. 7. Governing Law This waiver and release shall be governed by and construed in accordance with the laws of the State of [State], without regard to its conflict of law principles. 8. Severability If any provision of this waiver is found to be unenforceable or invalid, that provision shall be severed from this agreement, and the remaining provisions shall remain in full force and effect. 9. Entire Agreement This document constitutes the entire agreement between the parties and supersedes any prior or contemporaneous agreements, understandings, or representations, whether written or oral, concerning the subject matter of this waiver.PUBLICITY WAIVER AND RELEASE(Required) I agree to the publicity waiver.1. Advanced Muscle Palpation, with office located at 650 Commerce Drive, Ste 155, Woodbury, MN (“Company”) would like to use and publicize the name, likeness, testimonial and other personal characteristics of myself (“Model”) in exchange for the intangible value he/she/they will gain by participating in the Company’s publicity programs. 2. I provide consent for the participation in Company’s publicity programs. I acknowledge and agree that I am responsible for the safety during the photo shoot. No additional consent or authorization is required for this document to be effective. 3. In exchange for good and valuable consideration I acknowledge has been received, I hereby grant Company and its affiliates, successors and assigns an irrevocable, perpetual and unrestricted right and permission to take, use, re-use, publish, and republish photographic portraits, pictures, video or other images of Model (“Images”). I further transfer and assign to the Company all right, title and interest, if any, to all copyrights related to the Images. 4. I understand and agree Company may change or alter the Images without restriction, use the Images in whole or composite, and the Images may be distributed through any type of media existing now or in the future, including without limitation in print media and on the Internet . I further understand and agree the Images may be used for advertising, public relations, promotion, art, commercial or other purposes. Finally, I understand and agree that any uses of the Images will be made by the Company without further consent from or compensation to me or Model. 5. I hereby authorize The Company, and its affiliates, successors to copy, exhibit, publish or distribute the Testimonial for purposes of publicizing The Company's programs or for any other lawful purpose. These statements may be used in printed publications, multimedia presentations, on websites or in any other distribution media. I agree that I will make no monetary or other claim against The Company for the use of the statement. In addition, I waive any right to inspect or approve the finished product, including written copy, wherein my likeness or my testimonial appears. I further understand and agree the Testimonial may be used for advertising, public relations, promotion, art, commercial or other purposes. 6. I hereby release and discharge the Company and its affiliates from any and all claims and demands that may arise out of or in connection with the taking or the use of the Images, including without limitation any and all claims for libel or violation of any right of publicity or privacy.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.
